Stressful life events and survival after breast cancer

Association between life events after diagnosis of breast cancer and metastasis

The objective was to examine the association between life events post diagnosis of breast câncer and metastasis. Cross-sectional study with 300 women attending a reference hospital in oncology in the Espírito Santo. Was used the instrument Life Events Units-LEU/VAS to evaluate life events reported by women. Data were analyzed by using the nonparametric Wilcoxon and chi-square tests. It was performed odds ratio calculation for the variables associated with metastasis. It was found that 21% of the sample reported at least one life event post diagnosis. Of the 46 women who developed metastases, 20 reported one or more life events (p = 0.001). The odds ratio calculated shows that having life events post diagnosis increases by 2.59 (1,37 - 4,91; p = 0,003) times the chance of developing metastasis. When considering the time between diagnosis and the onset of metastasis there was a median of 18.0 months. The study shows a relationship between life events and metastasis, however emphasize the importance of a more complex analysis to better understand the impacts of these events on the onset and progression of breast cancer.

Association of stressful life events with accelerated bone loss in older men: the osteoporotic fractures in men (MrOS) study

Prior studies suggest an association between stressful life events and fractures that may be mediated by BMD. In the current study, risk of accelerated hip BMD loss was higher in older men with any type of stressful life event and increased with the number of types of stressful life events.

INTRODUCTION

Prior studies suggest that stressful life events may increase adverse health outcomes, including falls and possibly fractures. The current study builds on these findings and examines whether stressful life events are associated with increased bone loss.

METHODS

Four thousand three hundred eighty-eight men aged ≥65 years in the Osteoporotic Fractures in Men study completed total hip bone mineral density (BMD) measures at baseline and visit 2, approximately 4.6 years later, and self-reported stressful life events data mid-way between baseline and visit 2, and at visit 2. We used linear regression to model the association of stressful life events with concurrent annualized total hip BMD loss, and log binomial regression or Poisson regression to model risk of concurrent accelerated BMD loss (>1 SD more than mean annualized change).

RESULTS

Men (75.3 %) reported ≥1 type of stressful life event, including 43.3 % with ≥2 types of stressful life events. Mean annualized BMD loss was -0.36 % (SD 0.88), and 13.9 % of men were categorized with accelerated BMD loss (about 5.7 % or more total loss). Rate of annualized BMD loss increased with the number of types of stressful life events after adjustment for age (p < 0.001), but not after multivariable adjustment (p = 0.07). Multivariable-adjusted risk of accelerated BMD loss increased with the number of types of stressful life events (RR, 1.10 [95 % confidence interval (CI), 1.04-1.16]) per increase of one type of stressful life event). Fracture risk was not significantly different between stressful life event-accelerated bone loss subgroups (p = 0.08).

CONCLUSIONS

In these older men, stressful life events were associated with a small, dose-related increase in risk of concurrent accelerated hip bone loss. Low frequency of fractures limited assessment of whether rapid bone loss mediates any association of stressful life events with incident fractures. Future studies are needed to confirm these findings and to investigate the mechanism that may underlie this association.

Do hassles mediate between life events and mortality in older men? Longitudinal findings from the VA Normative Aging Study

We investigated whether hassles mediated the effect of life events on mortality in a sample of 1293 men (Mage=65.58, SD=7.01), participants in the VA Normative Aging Study. We utilized measures of stressful life events (SLE) and hassles from 1989 to 2004, and men were followed for mortality until 2010. For life events and hassles, previous research identified three and four patterns of change over time, respectively, generally indicating low, moderate, and high trajectories, with one moderate, non-linear pattern for hassles (shallow U curve). Controlling for demographics and health behaviors, we found that those with moderate SLE trajectories (38%) more likely to die than those with low SLE trajectories, HR=1.42, 95% CI [1.16, 3.45]. Including the hassles classes showed that those with the moderate non-linear hassles trajectory were 63% more likely to die than those with low hassles trajectory, HR=1.63, 95% CI [1.19, 2.23], while those with consistently high hassles trajectory were over 3 times more likely to die, HR=3.30, 95% CI [1.58, 6.89]. However, the HR for moderate SLE trajectory decreased only slightly to 1.38, 95% CI [1.13, 1.68], suggesting that the two types of stress have largely independent effects on mortality. Research is needed to determine the physiological and behavioral pathways through which SLE and hassles differentially affect mortality.

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.

Loss of partner and breast cancer prognosis - a population-based study, Denmark, 1994-2010

BACKGROUND

The extent to which experiencing a stressful life event influences breast cancer prognosis remains unknown, as the findings of the few previous epidemiological studies are inconsistent. This large population-based study examines the association between a common major life event, loss of a partner and breast cancer recurrence and all-cause mortality.

METHODS

N=21,213 women diagnosed with a first primary breast cancer 1994-2006, who had a cohabiting partner in the 4 years before their breast cancer diagnosis, were followed for death and recurrence in population-based registers and clinical databases. Information on education, disposable income, comorbidity and prognostic risk factors were included in Cox regression analyses.

RESULTS

Women who had lost a partner either before diagnosis or in subsequent years were not at significantly higher risk of recurrence or dying than women who had not lost a partner.

CONCLUSION

Our results do not support the concern that experiencing a stressful life event, the loss of a partner, negatively affects prognosis of breast cancer.

Do Stress Trajectories Predict Mortality in Older Men? Longitudinal Findings from the VA Normative Aging Study

We examined long-term patterns of stressful life events (SLE) and their impact on mortality contrasting two theoretical models: allostatic load (linear relationship) and hormesis (inverted U relationship) in 1443 NAS men (aged 41-87 in 1985; M = 60.30, SD = 7.3) with at least two reports of SLEs over 18 years (total observations = 7,634). Using a zero-inflated Poisson growth mixture model, we identified four patterns of SLE trajectories, three showing linear decreases over time with low, medium, and high intercepts, respectively, and one an inverted U, peaking at age 70. Repeating the analysis omitting two health-related SLEs yielded only the first three linear patterns. Compared to the low-stress group, both the moderate and the high-stress groups showed excess mortality, controlling for demographics and health behavior habits, HRs = 1.42 and 1.37, ps <.01 and <.05. The relationship between stress trajectories and mortality was complex and not easily explained by either theoretical model.

Impact of recent life events on the health related quality of life of adolescents and youths: the role of gender and life events typologies in a follow-up study

Background

Most studies on the effect of life events (LEs) have been carried out in convenience samples which cannot be considered representative of the general population. In addition, recent studies have observed that gender differences in the health related quality of life (HRQoL) impact of LEs might be lower than believed. We assessed the relationship between LEs and HRQoL in a representative sample of Spanish adolescents/youths, focusing on gender differences.

Methods

Participants (n = 840) completed the KIDSCREEN-27 to measure HRQoL at baseline and again after 3 years (n = 454). Follow-up assessment included the Coddington Life Events Scales (CLES) to measure LEs experiences in the previous 12 months. Respondents were categorized according to the amount of stress suffered. We calculated both the number of LEs and the Life Change Unit (LCU) score, a summary of the amount of stress inherent to the event and the time elapsed since occurrence. LEs were classified as desirable or undesirable, and family-related or extra-family. Effect sizes were calculated to evaluate changes in HRQoL. To assess the impact of LEs typologies, multiple linear regression models were constructed to evaluate their effect on HRQoL.

Results

Girls reported a mean 5.7 LEs corresponding to 141 LCUs, and boys 5.3 and 129, respectively. The largest impact of LEs on HRQoL was observed in the group of boys that reported to have lived more stress (third tertil of LCUs distribution). The linear association between LEs and HRQoL tended to be stronger among boys than girls, but the difference was not statistically significant. The effect on HRQoL was deemed important when undesirable events had been experienced. To have an important impact on HRQoL, 200 LCUs due to undesirable events were necessary in boys. In girls, slightly higher scores were necessary for a similar impact.

Conclusions

A moderate association was found between recent LEs and HRQoL, mainly among those who experienced several undesirable events that correspond to at least 200 LCUs. No gender differences were found in this association. Results may be useful for identifying adolescents with particular health risks, regardless of gender.

Depression, cortisol, and suppressed cell-mediated immunity in metastatic breast cancer

Cancer treatment is known to have significant immuno-suppressive/dysregulatory effects. Psychological distress and depression, which often accompany cancer diagnosis and treatment, can also suppress or dysregulate endocrine and immune function. Cell-mediated immunity (CMI) is critical for protection against a host of pathogens to which cancer patients may be particularly susceptible. CMI is also important for defense against some tumors. This study explored relationships among depressive symptoms, cortisol secretion, and CMI responses in 72 women with metastatic breast cancer. Depressive symptoms were assessed with the Center for Epidemiologic Studies-Depression Scale (CES-D). Saliva was sampled throughout the day over a 3-day period to obtain a physiologic index of diurnal cortisol concentrations and rhythmicity, which is associated with breast cancer survival time. CMI for specific antigens was measured following intradermal administration of seven commonly encountered antigens (tuberculin, tetanus, diphtheria, Streptococcus, Candida, Trichophyton, and Proteus). Analyses adjusting for relevant medical and treatment variables indicated that women reporting more depressive symptoms showed suppressed immunity as measured by lower average induration size. Women with higher mean diurnal cortisol concentrations also showed suppressed immunity as indicated by a decreased number of antigens to which positive reactions were measured. This study highlights the relationships among depression, stress, and immune function in the context of advanced breast cancer.

A prospective examination of perceived stress as a mediator of the relationship between life-events and QOL following breast cancer

OBJECTIVES

This study prospectively investigated the relationship between life-events, perceived stress, and quality of life (QOL) following breast cancer diagnosis, using the bio-behavioural model of cancer stress as a framework.

DESIGN

A longitudinal, self-report design was used.

METHODS

Three waves of data from 10,543 mid-aged Australian women (aged 45-50 at Survey 1) were collected over 5 years as part of a population-based survey. From this group a subsample (N=140) were identified who did not have breast cancer at Survey 1, but who subsequently developed breast cancer. Random regression growth curve analyses were used to investigate whether perceived stress mediated the relationship between initial life-events and change in QOL functioning overtime.

RESULTS

Prospective evidence was generated for each of the three criteria for testing mediation. As the number of life-events before breast cancer increased, women were significantly more likely to experience corresponding increases in perceived stress over the 5-year period. As the level of perceived stress before breast cancer increased, women were more likely to experience deteriorations overtime in role emotional, role physical, vitality, bodily pain, physical functioning, and social functioning. As the number of life-events before breast cancer increased, women were at significant risk of experiencing deteriorations overtime in bodily pain, social functioning, role emotional, and vitality. Mediational analyses revealed that perceived stress fully mediated the relationship between initial life-events and two QOL domains; role-emotional and social functioning.

CONCLUSION

Results partially supported the bio-behavioural model of cancer stress, but the model does not appear to fit the data as well as predicted, and may require revision.

Does the occurrence of adverse life events in patients with breast cancer lead to a change in illness behaviour?

GOALS OF WORK

It was examined whether life-changing events may lead to changes of illness behaviour in women prior to breast cancer diagnosis. We considered the delay in three different aspects: date of breast self-examination, routine visits at the doctor, and finally changes in the length of time intervals between the detection of suspicious breast symptoms and the subsequent verification of diagnoses.

MATERIALS AND METHODS

The data of 240 patients (age <70 years) with a first manifestation of breast cancer were used for analysis. Life events were assessed by means of a semi-structured interview as proposed by Brown and Harris and classified according to a system proposed by Brugha et al., the List of Threatening Experiences (LTE). All analyses were performed by means of Cox's proportional hazard regression.

MAIN RESULTS

Women with stressful events went to the doctor earlier than those without events. The date of breast self-examination remained unchanged after the occurrence of events. Women who had discovered suspicious breast symptoms delayed the subsequent visit at the doctor if they had experienced two serious events within this period. The occurrence of life events may have effects on illness behaviour, but into different directions.

CONCLUSION

In the majority of cases, event-related delays were shorter than those reported to aggravate the prognosis of breast cancer.

Stressful life-events exposure is associated with 17-year mortality, but it is health-related events that prove predictive

OBJECTIVES

Despite the widely-held view that psychological stress is a major cause of poor health, few studies have examined the relationship between stressful life-events exposure and death. The present analyses examined the association between overall life-events stress load, health-related and health-unrelated stress, and subsequent all-cause mortality.

DESIGN

This study employed a prospective longitudinal design incorporating time-varying covariates.

METHODS

Participants were 968 Scottish men and women who were 56 years old. Stressful life-events experience for the preceding 2 years was assessed at baseline, 8-9 years and 12-13 years later. Mortality was tracked for the subsequent 17 years during which time 266 participants had died. Cox's regression models with time-varying covariates were applied. We adjusted for sex, occupational status, smoking, BMI, and systolic blood pressure.

RESULTS

Overall life-events numbers and their impact scores at the time of exposure and the time of assessment were associated with 17-year mortality. Health-related event numbers and impact scores were strongly predictive of mortality. This was not the case for health-unrelated events.

CONCLUSIONS

The frequency of life-events and the stress load they imposed were associated with all-cause mortality. However, it was the experience and impact of health-related, not health-unrelated, events that proved predictive. This reinforces the need to disaggregate these two classes of exposures in studies of stress and health outcomes.

Stress history and breast cancer recurrence

BACKGROUND

There is mixed evidence regarding the possible association between a history of stressful or traumatic life events and more rapid breast cancer progression.

METHOD

Retrospective reports of past experiences of traumatic life events were assessed among 94 women with metastatic or recurrent breast cancer. A traumatic event assessment was conducted using the event-screening question from the posttraumatic stress disorder (PTSD) module of the Structured Clinical Interview for the DSM-IV-TR (SCID; 2002). Each reported event was judged by two independent raters to determine whether it met DSM-IV-TR PTSD A1 criteria for a traumatic event. Those events that did not meet such criteria were designated "stressful events."

RESULTS

Nearly 42% of the women in the sample were judged to have experienced one or more traumatic events; 28.7% reported only stressful events. A Kruskal-Wallis test found significant differences in disease-free interval among the three groups [chi2 (2, N=94)=6.09, P<.05]. Planned comparisons revealed a significantly longer disease-free interval among women who had reported no traumatic or stressful life events (median=62 months) compared to those who had experienced one or more stressful or traumatic life events (combined median=31 months).

CONCLUSIONS

A history of stressful or traumatic life events may reduce host resistance to tumor growth. These findings are consistent with a possible long-lasting effect of previous life stress on stress response systems such as the hypothalamic-pituitary-adrenal (HPA) axis.

Depression, quality of life and breast cancer: a review of the literature

Depression is misdiagnosed and undertreated among breast cancer population. Risk factors for depression in the 5 years after diagnosis are related more to the patient rather than to the disease or its treatment. The breast cancer stage (early and advanced) is not statistically significant in terms of rates of psychosocial distress except for recurrence. Risk factors of depression might impair quality of life such as fatigue, past history or recent episode of depression after the onset of cancer, cognitive attitudes of helplessness/hopelessness, resignation. Body image impairment from mastectomy and sexuality aftermath generates higher rates of mood disorders. The link between increased risk of breast cancer and depression is controversial among the literature. Some studies suggest a protective factor, others find a relation between stress, immunity and cancer occurrence or even mortality. Breast cancer survivors report a higher prevalence of mild to moderate depression with a lower quality of life in all areas except for family functioning. Treatment of depression in breast cancer women improves their quality of life and may increase longevity. Antidepressant medications remain the cornerstone of depression treatment. The hypothetical link between their prescription and increased breast cancer risk is not supported by literature's data.

Depression, Immunity, and Survival in Patients With Hepatobiliary Carcinoma

Purpose

The aims of the present study were to assess the prevalence of depressive symptoms at diagnosis, test the association between depressive symptoms and survival, and preliminarily test a mediational model of depression, immunity, and survival in patients with hepatobiliary carcinoma (HBC).

Patients and Methods

One hundred one patients diagnosed with HBC were prospectively studied. Depressive symptoms were measured at diagnosis using the Center for Epidemiological Studies Depression Scale (CES-D). Sociodemographic and disease-specific data were gathered from the patients' charts. In a subsample of patients, stress; alcohol, tobacco, and drug use; sleep quality; physical activity; social support; natural killer (NK) cell number and cytotoxicity; and plasma levels of interleukin (IL) -4, IL-5, tumor necrosis factor alpha, and interferon gamma were measured. Survival was measured from date of diagnosis to death.

Results

At diagnosis, 37% of patients reported a CES-D score of ≥ 16 (clinical range). Using Cox regression analysis, sociodemographic and disease-specific variables and CES-D score significantly predicted survival (Breslow χ2= 32.4, P = .006). Only vascular invasion (P = .001) and CES-D score ≥ 16 (P = .03) were significant predictors. In a subsample of 23 patients, patients who reported a CES-D score of ≥ 16 were found to have significantly lower NK cell numbers than patients who reported a CES-D score of less than 16 (F1,21= 9.39, P = .003). A robust trend was found in which NK cell number was associated with survival. A mediational model linking depressive symptoms and survival, with NK cell number as a mediator, was preliminarily supported.

Conclusion

Secondary to the high prevalence of depressive symptoms and impact on survival, psychological and pharmacologic interventions should be designed and implemented in patients diagnosed with HBC.

Contextual life stress and coping strategies as predictors of adjustment to breast cancer survivorship

BACKGROUND/PURPOSE

The study presented here examined the influence of contextual life stress and coping strategies on change in adjustment over the year following completion of treatment for breast cancer. We also investigated whether contextual stressful life events moderate the relationship between coping strategies and adjustment, such that cancer-specific emotional approach coping processes would predict better psychosocial outcomes only in the context of lower life stress and would have less impact on adaptation in the context of heightened life stress.

METHODS

In a sample of women (n = 558) who had recently completed treatment for nonmetastatic breast cancer and were part of a psychoeducational intervention trial to facilitate the transition to survivorship, life stress in the year prior to study entry, cancer-specific coping strategies, and general and cancer-specific adjustment were assessed at baseline, and adjustment outcomes (i.e., vitality, depressive symptoms, cancer-specific distress, personal growth) also were assessed at 6-month (n = 417) and 12-month (n = 397) follow-up.

RESULTS/CONCLUSIONS

Although cross-sectional relationships between life stress and adjustment were demonstrated, findings suggest that contextual life stress does not appear to have a direct influence on change in adjustment in the first year after breast cancer treatment. Instead, life stress interacted with cancer-specific coping to predict adjustment, such that cancer-specific emotional approach coping was adaptive only under conditions of low contextual life stress.

Cognitive Processes Underlying Coping Flexibility: Differentiation and Integration

This study investigates how individuals formulate flexible coping strategies across situations by proposing differentiation and integration as two stress-appraisal processes. Results showed that participants who coped more flexibly adopted the dimensions of controllability and impact in differentiating among different stressful situations. They also deployed an integrated strategy: the deployment of more monitoring in situations perceived as controllable but less of this strategy in situations perceived as uncontrollable. Participants who coped less flexibly did not adopt any given dimensions and tended to use more monitoring regardless of situational characteristics. These results suggest that individuals with different extents of coping flexibility differ in the cognitive processes. Individuals who cope more flexibly display a greater extent of differentiation and integration than do those who cope less flexibly. These findings are translated into strategies for stress management workshops.

Psychological factors and cancer development: Evidence after 30 years of research

The question whether psychological factors affect cancer development has intrigued both researchers and patients. This review critically summarizes the findings of studies that have tried to answer this question in the past 30 years. Earlier reviews, including meta-analyses, covered only a limited number of studies, and included studies with a questionable design (group-comparison, cross-sectional or semiprospective design). This review comprises only longitudinal, truly prospective studies (N=70). It was concluded that there is not any psychological factor for which an influence on cancer development has been convincingly demonstrated in a series of studies. Only in terms of 'an influence that cannot be totally dismissed,' some factors emerged as 'most promising': helplessness and repression seemed to contribute to an unfavorable prognosis, while denial/minimizing seemed to be associated with a favorable prognosis. Some, but even less convincing evidence, was found that having experienced loss events, a low level of social support, and chronic depression predict an unfavorable prognosis. The influences of life events (other than loss events), negative emotional states, fighting spirit, stoic acceptance/fatalism, active coping, personality factors, and locus of control are minor or absent. A methodological shortcoming is not to have investigated the interactive effect of psychological factors, demographic, and biomedical risk factors.

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.

An international comparison of breast cancer survival: Winnipeg, Manitoba and Des Moines, Iowa, metropolitan areas

PURPOSE

Extending previous Canadian-United States cancer survival comparisons in large metropolitan areas, this study compares breast cancer survival in smaller metropolitan areas: Winnipeg, Manitoba and Des Moines, Iowa.

METHODS

Manitoba and Iowa cancer registries, respectively, provided a total of 2,383 and 1,545 women with breast cancer (1984 to 1992, followed until December 31, 1997). Socioeconomic data for each person's residence at the time of diagnosis was taken from population censuses.

RESULTS

Socioeconomic status and breast cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Des Moines, residents of the lowest fifth of income areas in Winnipeg experienced a significant 5-year survival advantage (survival rate ratio [SRR] = 1.14). In these lowest income areas, the Canadian survival advantage was larger among women aged 25 to 64 years (SRR = 1.23), and this was observed in the middle fifth of income areas among this younger cohort (SRR = 1.11). The Canadian survival advantage even seemed apparent in the poorest neighborhoods with relatively high representations of Aboriginal people (SRR = 1.16).

CONCLUSION

This study replicated the finding of advantaged Canadian cancer survival in smaller metropolitan areas that had been consistently observed in larger metropolitan areas. Canada's single payer health care system seems to offer similar advantages across a number of diverse urban contexts.