The effects of surgical stress and psychological stress on the immune function of operative cancer patients

When Experiencing a Surgery: Gastrointestinal Cancer Patients’ Longitudinal Trajectories in Psychological Stress and Their Association with Quality of Recovery

Objective

Surgical treatment, particularly for gastrointestinal cancer, is a burdensome prospect for many patients. Psychological stress is a common complaint; however, little is known about its patterns in perioperative patients. This study aimed to identify distinct trajectories of perioperative stress and explore antecedent factors and hospitalization outcomes among different trajectories in patients with gastrointestinal cancer.

Methods

A longitudinal study was conducted on 203 patients with gastrointestinal surgical cancer at a specialized oncology hospital in China. Psychological stress was assessed at five perioperative time points (1–3 days before surgery; 1–3 days, 4–6 days, 7–9 days after surgery, and before discharge). A growth mixture model was used to analyze the potential stress trajectories. Multinomial logistic regression was used to identify the characteristics associated with different trajectories.

Results

Three stress trajectories were identified: recovery class (RC, 60.6%), chronic class (CC, 29.5%), and deterioration class (DC, 9.9%). Compared with CC, RC exhibited a shorter length of stay and better recovery quality, and was related to employment, low illness perception, and positive coping; DC reported lower recovery quality from 7 to 9 days after surgery to discharge and was associated with poor education level, history of surgery, stoma, smoking, and preoperative insomnia.

Conclusions

Most surgical patients were insulated from stress due to psychosocial resources, and thus displayed good recovery. However, many patients had moderate stress that did not improve or worsen over the perioperative period, which still needs to be screened and provided with early stress management.

Effects of family cohesion and heart rate reactivity on aggressive/rule-breaking behavior and prosocial behavior in adolescence: The Tracking Adolescents' Individual Lives Survey study

The biological sensitivity to context hypothesis posits that high physiological reactivity (i.e., increases in arousal from baseline) constitutes heightened sensitivity to environmental influences, for better or worse. To test this hypothesis, we examined the interactive effects of family cohesion and heart rate reactivity to a public speaking task on aggressive/rule-breaking and prosocial behavior in a large sample of adolescents (N = 679; M age = 16.14). Multivariate analyses revealed small- to medium-sized main effects of lower family cohesion and lower heart rate reactivity on higher levels of aggressive/rule-breaking and lower levels of prosocial behavior. Although there was some evidence of three-way interactions among family cohesion, heart rate reactivity, and sex in predicting these outcome variables, these interactions were not in the direction predicted by the biological sensitivity to context hypothesis. Instead, heightened reactivity appeared to operate as a protective factor against family adversity, rather than as a susceptibility factor. The results of the present study raise the possibility that stress reactivity may no longer operate as a mechanism of differential susceptibility in adolescence.

Psychosocial intervention effects on adaptation, disease course and biobehavioral processes in cancer

A diagnosis of cancer and subsequent treatments place demands on psychological adaptation. Behavioral research suggests the importance of cognitive, behavioral, and social factors in facilitating adaptation during active treatment and throughout cancer survivorship, which forms the rationale for the use of many psychosocial interventions in cancer patients. This cancer experience may also affect physiological adaptation systems (e.g., neuroendocrine) in parallel with psychological adaptation changes (negative affect). Changes in adaptation may alter tumor growth-promoting processes (increased angiogenesis, migration and invasion, and inflammation) and tumor defense processes (decreased cellular immunity) relevant for cancer progression and the quality of life of cancer patients. Some evidence suggests that psychosocial intervention can improve psychological and physiological adaptation indicators in cancer patients. However, less is known about whether these interventions can influence tumor activity and tumor growth-promoting processes and whether changes in these processes could explain the psychosocial intervention effects on recurrence and survival documented to date. Documenting that psychosocial interventions can modulate molecular activities (e.g., transcriptional indicators of cell signaling) that govern tumor promoting and tumor defense processes on the one hand, and clinical disease course on the other is a key challenge for biobehavioral oncology research. This mini-review will summarize current knowledge on psychological and physiological adaptation processes affected throughout the stress of the cancer experience, and the effects of psychosocial interventions on psychological adaptation, cancer disease progression, and changes in stress-related biobehavioral processes that may mediate intervention effects on clinical cancer outcomes. Very recent intervention work in breast cancer will be used to illuminate emerging trends in molecular probes of interest in the hope of highlighting future paths that could move the field of biobehavioral oncology intervention research forward.

Self-assessed parental depressive problems are associated with blunted cortisol responses to a social stress test in daughters. The TRAILS Study

Depression runs in families and is considered a stress-related disorder. Familial risk for depression may be transmitted via deregulated psychophysiological stress responses from parent to child. In this study, we examined the association between self-assessed lifetime parental depressive problems (PDP) and adolescent offspring' cortisol responses to a social stress test. Data were collected as part of the third assessment wave of TRAILS (TRacking Adolescents' Individual Lives Survey), a large prospective population study of Dutch adolescents. Data of 330 adolescents (mean age 16.04; 40.9% girls) who participated in a laboratory session, including a standardized performance-related social stress task (public speaking and mental arithmetic) were examined. Four saliva cortisol samples were collected before, during and after the social stress task which were analyzed with repeated measures Analysis of Variance. Lifetime parental depressive problems were assessed by self-reports from both biological parents. PDP was associated with daughter' cortisol responses (F(3,133)=3.90, p=.02), but no association was found in sons (F(3,193)=0.27, p=.78). Girls whose parents ever experienced depressive symptoms displayed a blunted cortisol response to the standardized social stress test, while girls whose parents never had such problems displayed the characteristic curvilinear response pattern. This effect was not mediated by offspring stress history (age 0-16). Analyses were corrected for smoking behaviour and adolescent depressed mood. The fact that PDP were measured by self-report questionnaires and did not reflect clinical DSM-IV diagnosis could be considered a limitation of the study.

NATURAL KILLER CELLS AND LYMPHOCYTES INCREASE IN WOMEN WITH BREAST CANCER FOLLOWING MASSAGE THERAPY

Women diagnosed with breast cancer received massage therapy or practiced progressive muscle relaxation (PMR) for 30-min sessions 3 times a week for 5 weeks or received standard treatment. The massage therapy and relaxation groups reported less depressed mood, anxiety, and pain immediately after their first and last sessions. By the end of the study, however, only the massage therapy group reported being less depressed and less angry and having more vigor. Dopamine levels, Natural Killer cells, and lymphocytes also increased from the first to the last day of the study for the massage therapy group. These findings highlight the benefit of these complementary therapies, most particularly massage therapy, for women with breast cancer.

Cognitive behavioral stress management effects on psychosocial and physiological adaptation in women undergoing treatment for breast cancer

BACKGROUND

A diagnosis of breast cancer and treatment are psychologically stressful events, particularly over the first year after diagnosis. Women undergo many demanding and anxiety-arousing treatments such as surgery, radiation and chemotherapy. Psychosocial interventions that promote psychosocial adaptation to these challenges may modulate physiological processes (neuroendocrine and immune) that are relevant for health outcomes in breast cancer patients.

METHODS

Women with Stages 1-3 breast cancer recruited 4-8 weeks after surgery were randomized to either a 10-week group-based cognitive behavioral stress management (CBSM) intervention or a 1-day psychoeducational control group and completed questionnaires and late afternoon blood samples at study entry and 6 and 12 months after assignment to experimental condition.

RESULTS

Of 128 women initially providing psychosocial questionnaire and blood samples at study entry, 97 provided complete data for anxiety measures and cortisol analysis at all time points, and immune assays were run on a subset of 85 of these women. Those assigned to a 10-week group-based CBSM intervention evidenced better psychosocial adaptation (lower reported cancer-specific anxiety and interviewer-rated general anxiety symptoms) and physiological adaptation (lower cortisol, greater Th1 cytokine [interleukin-2 and interferon-gamma] production and IL-2:IL-4 ratio) after their adjuvant treatment compared to those in the control group. Effects on psychosocial adaptation indicators and cortisol appeared to hold across the entire 12-month observation period. Th1 cytokine regulation changes held only over the initial 6-month period.

CONCLUSIONS

This intervention may have facilitated a "recovery or maintenance" of Th1 cytokine regulation during or after the adjuvant therapy period. Behavioral interventions that address dysregulated neuroendocrine function could play a clinically significant role in optimizing host immunologic resistance during a vulnerable period.

Adolescents' cortisol responses to awakening and social stress; effects of gender, menstrual phase and oral contraceptives. The TRAILS study

Studies on the influence of sex hormones on cortisol responses to awakening and stress have mainly been conducted in adults, while reports on adolescents are scarce. We studied the effects of gender, menstrual cycle phase and oral contraceptive (OC) use on cortisol responses in a large sample of adolescents. Data come from TRAILS (TRacking Adolescents' Individual Lives Survey), a prospective population study of Dutch adolescents. This study uses data of 644 adolescents (age 15-17 years, 54.7% boys) who participated in a laboratory session including a performance-related social stress task (public speaking and mental arithmetic). Free cortisol levels were assessed by multiple saliva samples, both after awakening and during the laboratory session. No significant effects of gender and menstrual phase on cortisol responses to awakening were found, while girls using OC displayed a slightly blunted response (F(1, 244)=5.30, p=.02). Cortisol responses to social stress were different for boys and free-cycling girls (F(3, 494)=9.73, p<.001), and OC users and free-cycling girls (F(3, 279)=15.12, p<.001). Unexpectedly, OC users showed no response at all but displayed linearly decreasing levels F(1, 279)=19.03, p<.001) of cortisol during the social stress test. We found no effect of menstrual cycle phase on cortisol responses to social stress (F(3, 157)=0.58, p=.55). The absence of a gender difference in the adolescents' cortisol awakening response found in this study is consistent with previous reports. Our results further suggest that adolescent OC users display slightly blunted cortisol responses after awakening, and that gender differences in cortisol responses to social stress during adolescence are comparable to those described for adult populations, that is, stronger responses in men than in women. Whereas previous work in adults suggested blunted stress responses in OC users compared to men and free-cycling women, adolescent OC users showed no cortisol response. Effects of type of OC could not be studied because of low numbers of OC that were only progestin based.

Relations of plasma ACTH and cortisol levels with the distribution and function of peripheral blood cells in response to a behavioral challenge in breast cancer: an empirical exploration by means of statistical modeling

This study explores by means of statistical modeling the relations between adrenocorticotrophin hormone (ACTH) and cortisol levels and distribution and function of peripheral blood cells in response to an acute stressor consisting of a standardized speech task in breast cancer patients with axillary lymph node metastases and distant metastases. As a control group age-matched women participated in this study. The preliminary findings show that the effect of ACTH on immunoreactivity is related to the health of the doctor. In node-positive breast cancer patients and healthy women, ACTH has a modest positive effect on T lymphocyte percentages and on pokeweed-induced proliferation at baseline and in response to the speech task. In contrast, in breast cancer patients with distant metastases, ACTH has a negative effect on T lymphocyte and function at baseline and in response to the stressor. Interestingly, neither ACTH nor cortisol levels were related to natural killer (NK) cell percentages and natural killer cell activity (NKCA). In addition, it appeared that cortisol had a positive effect on CD3 cell percentages when the health of the donor was taken into account. This effect was most distinct on CD3 cells measured at baseline. If replicated on a larger scale, these findings may indicate that the hypothalamic pituitary adrenal axis plays a role in the adaptation of the host defenses in reaction to acute stress, particularly those involving T lymphocytes. Moreover, these findings may suggest that the health of the donor may be an important effect modification factor in the relations between neuroendocrines and immunoreactivity.

Health psychology: psychosocial and biobehavioral aspects of chronic disease management

Psychosocial factors appear to impact upon the development and progression of such chronic diseases as coronary heart disease, cancer, and HIV/AIDS. Similarly, psychosocial interventions have been shown to improve the quality of life of patients with established disease and seem to influence biological processes thought to ameliorate disease progression. Small-scale studies are useful for specifying the conditions under which psychosocial factors may or may not impact quality of life, biological factors, and disease progression. They are also useful for informing us about the conditions under which psychosocial interventions can serve as adjuvants (e.g. adherence training) to medical treatments. Only large-scale clinical trials, however, can determine the extent to which these psychosocial interventions may impact morbidity and mortality.

Effectiveness of a short-term group psychotherapy program on endocrine and immune function in breast cancer patients: an exploratory study

Cancer patients who had been treated for early stage breast cancer and were diagnosed with either positive axillary lymph nodes or distant metastases were randomly assigned to either a 13-week experiential-existential group psychotherapy (EEGP) program or a waiting list control (WLC) condition. Endocrine and immune measures were obtained before and after the intervention period. The findings of this study are that, after the 13 weeks of the experiment, patients in the EEGP group showed lower levels of plasma cortisol and lower levels of prolactin as well as lower percentages of natural killer cells, CD8 cells, and CD4 cells in addition to a lower proliferative response to pokeweed mitogen than patients in the WLC group. Importantly, this was only found in those breast cancer patients presenting relatively high endocrine and immune baseline levels, suggesting that the patients' profile with regard to endocrine and immune function at the start of a program can have an important effect. If replicated on a larger scale, the current results may be relevant for the treatment of breast cancer.