Cancer survivors’ and partners’ key concerns and quality of life

Objective: Understanding the concerns of cancer survivors is essential for effective interventions. This study was designed to identify the primary concerns of dyads coping with cancer, how concerns differed by role and sex, and whether concerns expressed during counselling were associated with survivors’ psychosocial well-being and adjustment.

Design: Forty-three dyads with breast and prostate cancer (N = 86 participants) were enrolled in an interpersonal telephone counselling intervention. Audio recordings of 228 counselling sessions were transcribed and content analysed qualitatively to identify major themes and key concerns. A total of three 30-min sessions were coded for each study participant. Quantitative data and statistical analyses were used to predict changes in survivors’ quality of life.

Main Outcome Measures: Participants completed psychosocial well-being measures (depression, positive/negative affect, and relationship satisfaction), pre- and post-counselling.

Results: Survivors’ concerns focused on cancer- and treatment-related issues, whereas partners’ concerns centred on the well-being of their spouse/partner with cancer, and what they were doing to help their loved one cope with his/her illness. Key concerns for all consisted of relationship maintenance and communication issues. Further, discussion of these concerns was predictive of significant improvements in adjustment post-counselling for women with breast cancer.

Conclusion: Discussion of interpersonal concerns may play a more important role in the well-being of women, than men, coping with cancer.     

A randomized controlled trial of expressive writing in breast cancer survivors with lymphedema

Objective: Breast cancer survivors who develop lymphedema report poorer quality of life (QoL) than those without lymphedema. Expressive writing is a potential intervention to address QoL.

Design: Adult women (N = 107) with breast cancer and chronic Stage II lymphedema were randomised to writing about thoughts and feelings specific to lymphedema and its treatment (intervention) or about daily activities (control) for four, 20-min sessions.

Main Outcome Measures: Outcome measures were several indicators of QoL assessed at baseline, one, three, and six months post-intervention (total scores and subscales of Upper Limb Lymphedema 27 and Functional Assessment of Cancer Therapy–Breast). Hypothesised moderators of change in QoL were dispositional optimism, avoidant behaviours, and time since lymphedema diagnosis.

Results: There was no statistically significant intent-to-treat main effects of expressive writing on QoL. Statistically significant moderating effects on change in different indicators of QoL were observed for all three moderators. Expressive writing was more effective for improving QoL in women who were higher on optimism, lower on avoidance and had less time since a lymphedema diagnosis.

Conclusion: These results provide further evidence that there are subsets of individuals for whom expressive writing is more effective. Future research may investigate targeting expressive writing based on identified moderators.     

Measuring illness representations in breast cancer survivors (BCS) prescribed tamoxifen: Modification and validation of the Revised Illness Perceptions Questionnaire (IPQ-BCS)

Objective: The Revised Illness Perceptions Questionnaire (IPQ-R), widely used to assess illness perceptions, may fail to measure unique characteristics of different illnesses. This study modified and validated the IPQ-R for breast cancer survivors to provide detailed understanding of the specific illness perceptions held by these patients.

Design: Initial modifications were made following qualitative interviews and were revised in a think-aloud study. The modified scale was tested in 753 breast cancer survivors prescribed tamoxifen. Modifications included adding a tamoxifen consequences scale and adapting the timeline scales to measure beliefs around risk of recurrence and cure. A confirmatory factor analysis was conducted on the modified questionnaire and an exploratory factor analysis on the causal beliefs scale. Test–retest reliability, internal consistency and construct validity were also examined.

Results: The proposed eight-factor structure showed acceptable model fit, with high loadings and good reliability for all subscales. Correlations between subscales were consistent with theory and previous research.

Conclusions: The IPQ-BCS is valid and reliable, and provides unique understanding of specific perceptions held by this population, including beliefs surrounding risk of recurrence and consequences of ongoing hormonal treatment. Identifying these perceptions will aid development of interventions targeting depression, fear of recurrence and medication non-adherence.     

Unemployment as a chronic stressor: A systematic review of cortisol studies

Objective: Unemployment is a type of chronic stressor that impacts human health. The reasons for how the stress of unemployment affect health is still a matter of discussion. One of the pathways from chronic stress to ill health is mediated by cortisol, and so we set out to compile extant data on how its secretion is affected by unemployment.

Design: A systematic literature search was conducted to establish the cortisol dysregulatory effects of this stressor.

Main outcome measures: Only studies that specifically examined the effects of unemployment on cortisol excretion, and were written in English were included.

Results: Ten reports were obtained and synthesised to determine the severity and complexity of the effect of unemployment on cortisol secretion. The resulting combined evidence is mixed in terms of degree or dynamic of relationship.

Conclusions: The differences between the cumulate findings of the studies can be understood in the context of the lack of both standardised methodology and an absence of consensus on unemployment definition. We propose existing methodologies may be strengthened by acknowledging and accounting for the individual characteristics that may be relevant to the stress experience of unemployment.     

Working mechanisms of a web-based self-management intervention for cancer survivors: a randomised controlled trial

Objective: The aim of this study was to investigate whether problem-solving skills and perceived personal control over cancer recovery mediated the intervention effects on depression and fatigue of a web-based computer-tailored intervention for cancer survivors – the Kanker Nazorg Wijzer (Cancer Aftercare Guide).

Design: Patients were recruited through 21 Dutch hospitals (November 2013–June 2014). The mediation model was tested in a randomised controlled trial with an intervention group (n = 231) and a waiting list control group (n = 231).

Main outcome measures: Hypothesised mediators problem-solving skills (SPSI-R) and personal control (IPQ-R) were measured at baseline and 3 months from baseline. Outcomes depression (HADS) and fatigue (CIS) were measured at baseline and 6 months from baseline.

Results: The intervention effects in decreasing depression and fatigue were mediated by personal control. Problem-solving skills did not mediate the intervention effects on depression and fatigue.

Conclusion: While personal control in the control group decreased in the first three months after baseline, levels of personal control within the intervention group were maintained. This effect partially explained the intervention effects on depression and fatigue. The results provide evidence for the relevance of addressing personal control in web-based interventions in order to improve psychosocial well-being in early cancer survivors.     

Mental health consequences of weight cycling in the first-year post-treatment for breast cancer

Objectives: Weight cycling is linked with advanced breast cancer diagnosis, increased risk of cancer reoccurrence and cancer-related mortality. While women treated for breast cancer report challenges with navigating their post-treatment body shape and weight, the effects of weight cycling on body image and mental health have not been elucidated. This study examined associations between weight changes and weight cycling on psychological health (i.e. weight-related guilt, shame and depressive symptoms) among women in the first-year post-treatment.

Design and Outcome Measures: Self-reported assessments of pre-cancer weight cycling, post-treatment weight-related guilt, shame and depressive symptoms, and objective assessments of weight were assessed in a longitudinal sample of 173 women treated for breast cancer (M_age = 55.01 ± 10.96 years).

Results: Based on findings from multilevel models, women experienced the most weight-related shame when their weight was heavier than their personal average. Additionally, heavier weight was associated with worse psychological health, particularly for women with a history of stable (vs. cycling) weight pre-cancer.

Conclusions: Weight cycling pre-cancer and post-treatment weight change have important implications for psychological well-being. Due to the potential psychological consequences associated with a history of weight cycling, targeted strategies are needed to improve overall health outcomes for women’s survivorship after breast cancer.     

Can self-affirmation exacerbate adverse reactions to stress under certain conditions?

Objective: Self-affirmation has repeatedly been shown to reduce adverse psychological and physiological responses to stress. However, it is plausible that self-affirmation could exacerbate negative reactions to stress under certain conditions. The current research explored whether self-affirmation would increase negative psychological responses to a stressor occurring in a central life domain characterised by low levels of control.

Design: Female participants (Study 1 N = 132; Study 2 N = 141) completed baseline measures of anxiety and mood. They were then randomly allocated to complete a self-affirmation or control task, before reading a narrative documenting a stressful birth and imagining themselves in the place of the woman giving birth. After completing this task, participants again reported their levels of anxiety and positive mood.

Main outcome measures: Anxiety and positive mood assessed at follow-up.

Results: Study 1 demonstrated that self-affirmed women experienced increased anxiety and less positive mood at follow-up, compared both to baseline and to women in the control condition. Study 2 revealed that the effect of self-affirmation on outcomes was moderated by fear of childbirth.

Conclusion: These results provide preliminary evidence that self-affirmation may worsen negative responses to stressors under certain conditions and for certain individuals.     

Being an optimist or a pessimist and its relationship with morning cortisol release and past life review in healthy older people

Objective: Investigate the relationship between optimism and pessimism and the cortisol awakening response (CAR) and past life review in healthy older people.

Design: 76 older volunteers summarised their lives, highlighting the most important events, impressions and experiences. Cortisol saliva samples were collected on two consecutive weekdays. High and low optimism and pessimism groups were computed by mean split.

Main Outcome Measures: Percentages of positive (PE) and negative events (NE) and positive (PCE) and negative cognitions and emotions (NCE) were obtained. Optimism and pessimism were measured with the Life Orientation Test Revised. The areas under the curve with respect to the ground and with respect to the increase were computed, with the latter understood as the CAR.

Results: The high pessimism group reported more NE and NCE and less PE and PCE (p’s < 0.041). No significant differences in CAR were found between high and low optimism and pessimism groups after removing suspected non-adherent participants (p’s > 0.116). Higher CAR was related to lower PCE, but higher NCE (both p < 0.008).

Conclusion: Pessimism seems to increase the focus on negative aspects of the past, which may lead to a worse perception of life in ageing, whereas optimism contributes to a healthier CAR.     

Positive and negative affectivity,stress, and well-being in African-Americans: Initial demonstration of a polynomial regression and response surface methodology approach

Objective: The extent to which positive (PA) and negative (NA) affect conjointly impact well-being is not yet well understood. Additionally, research investigating the role of affectivity in maintaining well-being among ethnic and racial minorities is scant. The current research demonstrates how polynomial regression and response surface methodology (PR and RSM) may be used to better understand how PA and NA jointly influence stress and well-being.

Design: In Study 1, 291 African-American undergraduates (M_age = 22.91, SD = 6.91; 67% female) completed measures of affectivity and psychological well-being. In Study 2, a community sample of 117 African-Americans (M_age = 31.87, SD = 13.83; 69% female) completed affectivity measures and a laboratory-based social stressor task to assess links between affectivity and salivary cortisol reactivity.

Main outcome measures: Study 1 included life satisfaction, perceived stress and self-reported depressive symptoms. Study 2 included salivary cortisol reactivity.

Results: Across both studies, PA ascendency (i.e. high PA combined with low NA) was associated with better well-being, while NA ascendancy (i.e. high NA combined with low PA) was associated with poorer outcomes.

Conclusion: PR and RSM may provide new insight into the conjoint influence of PA and NA on health and well-being. We discuss potential implications for affectivity research, including race-related explorations.     

‘It was all intertwined’: Illness representations and self-management in patients with cancer and anxiety/depression

Objective: Cancer and anxiety/depression frequently co-occur, leading to poorer outcomes for these illnesses. However, the majority of existing research investigates how participants view single illnesses alone. This study aimed to explore the content of individuals’ multimorbid representations and how these relate to their coping behaviours and self-management strategies for cancer and anxiety/depression.

Design: A semi-structured qualitative research design with theoretical thematic analysis.

Main Outcome Measures: Multimorbid illness representations, coping behaviours, and self-management strategies.

Results: In interviews with 21 participants multimorbid representations varied, three participants viewed cancer and anxiety/depression as unrelated, five participants were uncertain about the relationship between cancer and anxiety/depression, and the majority of participants perceived cancer and anxiety/depression as related. This third group of participants often described relationships as causal, with representations having both positive and negative influences on coping behaviours and self-management strategies. Representations were shown to change over the course of the cancer experience, with fear of cancer recurrence and the influence of participants’ most challenging illness also discussed.

Conclusions: People hold multimorbid illness representations that can influence self-management. An awareness of these representations by researchers, health professionals, and patients is important for the creation of future interventions that aim to improve and maintain patient wellbeing.     

Increased cognitive problem reporting after information about chemotherapy-induced cognitive decline: The moderating role of stigma consciousness

Objective: Information about treatment side effects can increase their occurrence; breast cancer (BC) patients showed increased cognitive problem reporting (CPR) and decreased memory performance after information about cognitive side effects. The current study extends previous research on adverse information effects (AIE) by investigating (a) risk factors, (b) underlying mechanisms and (c) an intervention to reduce AIE.

Design: In an online experiment, 175 female BC patients were randomly assigned to one of three conditions. In the two experimental groups, patients were informed about the possible occurrence of cognitive problems after chemotherapy with (intervention group) or without (experimental group) reassuring information that ‘there are still patients who score well on memory tests’. In the control group, no reference to chemotherapy-related cognitive problems was made.

Main outcome measures: Main dependent measure was CPR. Four moderating and five mediating processes were examined.

Results: CPR increased with higher levels of stigma consciousness in the two experimental groups, but not in the no-information control group.

Conclusion: Merely informing patients about cognitive side effects may increase their occurrence, especially among individuals vulnerable to patient stereotypes. Adding reassuring information is not sufficient to reduce AIE.     

Differential disgust responding in people with cancer and implications for psychological wellbeing

Objectives: Evidence suggests that disgust responses, known to negatively affect psychological wellbeing, may differ in people with cancer. We performed the first quantitative investigation of three discrete types of disgust trait – disgust propensity, sensitivity and self-directed disgust – in people diagnosed with a broad range of cancers (versus cancer-free controls), and explored their associations with psychological wellbeing.

Design: In a cross-sectional survey design, 107 participants with heterogeneous cancer diagnoses, recruited from cancer charities and support groups, were matched with cancer-free controls by age and gender.

Outcome measures: Measures of the three disgust traits were taken alongside measures of anxiety and depression.

Results: Disgust sensitivity and physical self-disgust were significantly higher in the cancer than control sample, while disgust propensity and behavioural self-disgust were lower. The disgust traits had a different pattern of associations to psychological wellbeing across the two groups, with disgust sensitivity predicting depressive symptoms to a significantly greater extent in the cancer than control group.

Conclusions: People with cancer differ from matched controls in their disgust responses and these responses have significant predictive relationships with aspects of their psychological wellbeing. The results suggest that emotion-based interventions may be useful for improving psychological wellbeing in people with cancer.     

“Why me?” – women’s use of spiritual causal attributions in making sense of breast cancer

Objective: This study addressed the role of positive (event is due to God’s Love or to God’s Will) and negative (event is due to God’s Anger) spiritual causal attributions in women’s adjustment to breast cancer.

Design: Ninety-three women diagnosed with breast cancer were assessed at six times from pre-diagnosis through two years post-surgery.

Main outcome measures: Women completed positive and negative measures of spiritual causal attributions (e.g. God’s Love), cognitive appraisals (e.g. threat), coping behaviour (e.g. avoidance) and well-being (e.g. distress).

Results: Positive spiritual attributions were consistently related to positive aspects of adjustment (e.g. positive appraisal, acceptance coping, and/or emotional well-being) while negative spiritual attribution was related to negative factors (e.g. appraisals of loss and uncontrollability, avoidance coping, and/or emotional distress). Path analyses revealed that the effects of positive and negative spiritual attributions on well-being were mediated by general cognitive appraisal and coping behaviour. Cross-lagged correlational analysis revealed a ‘downward spiral’ effect wherein the negative attribution of God’s Anger at pre-diagnosis predicted greater distress at 1 week pre-surgery which in turn predicted an increase in the negative attribution and so on across time.

Conclusion: Although positive spiritual attributions may help women maintain an attitude of hope and acceptance in the face of cancer, results indicate that the effects of negative spiritual attribution can play a significant role in undermining their well-being.     

The role of the affect heuristic and cancer anxiety in responding to negative information about medical tests

Objective: Little is known about the affective implications of communicating negative information about medical tests. This research explored how affective processes – particularly the Affect Heuristic and cancer anxiety – influence the way in which people respond to such information.

Design: Participants received different types of information about PSA screening for prostate cancer and magnetic resonance imaging (MRI) scans for migraine headaches. This was a 2 (Test harm information: present vs. absent) × 2 (Test benefit information: present vs. absent) × 2 (Test recommendation: present vs. absent) between-participants design.

Outcome Measures: Perceived risk, perceived benefit and general attitudes towards PSA and MRI testing, cancer anxiety, preferences to receive the tests vs. not.

Results: As predicted by the Affect Heuristic, test harm information reduced perceived test benefits. However, information about uncertain test benefit did not increase perceived test risks. Information about the test reduced cancer anxiety, indicating defensive coping. These variables – affect, anxiety, perceived risks and benefits – all uniquely predicted test preferences.

Conclusion: Affective processes play an important role in how people respond to and interpret negative information about medical tests. Information about harms and information about the lack of benefit can both make a test seem less beneficial, and will reduce cancer anxiety as a result.     

Explaining the effects of a decision intervention on mammography intentions: The roles of worry,fear and perceived susceptibility to breast cancer

Objective: This study examines the effects of a mammography decision intervention on perceived susceptibility to breast cancer (PSBC) and emotion and investigates how these outcomes predict mammography intentions.

Design: Randomised between-subjects online experiment. Participants were stratified into two levels of risk. Within each stratum, conditions included a basic information condition and six decision intervention conditions that included personalised risk estimates and varied according to a 2 (amount of information: brief vs. extended) × 3 (format: expository vs. untailored exemplar vs. tailored exemplar) design. Participants included 2465 US women ages 35–49.

Main Outcome Measures: PSBC as a percentage, PSBC as a frequency, worry, fear and mammography intentions.

Results: The intervention resulted in significant reductions in PSBC as a percentage for women in both strata and significant increases in worry and fear for women in the upper risk stratum. Of the possible mediators examined, only PSBC as a percentage was a consistent mediator of the effect of the intervention on mammography intentions.

Conclusion: The results provide insight into the mechanism of action of the intervention by showing that PSBC mediated the effects of the intervention on mammography intentions.     

Physical and mental health trajectories of cancer patients and caregivers across the year post-diagnosis: a dyadic investigation

Objective: Evidence suggests interdependence between cancer patients’ and their caregivers’ physical and mental health. However, the extent to which caregivers’ health relates to their patients’ recovery, or patients’ health affects their caregivers’ outcomes, is largely unknown. This dyadic investigation reports the relations between cancer patients’ and their caregivers’ physical and mental health trajectories during the year following diagnosis.

Design: Ninety-two colorectal cancer patient–caregiver dyads completed questionnaires at 2, 6 and 12 months post-diagnosis.

Outcome measures: Self-reported physical and mental health using the Medical Outcomes Study Short Form Health Survey-12.

Results: Patients reported improved physical health over the year following their diagnosis, whereas caregivers reported declining physical health. Patients with lower mental health at diagnosis had stagnated physical health recovery. Caregivers’ physical health declined most noticeably among those reporting low mental health at diagnosis and whose patients reported low physical health at diagnosis.

Conclusion: Findings suggest targeting health interventions to cancer patients and caregivers reporting poor mental health at diagnosis may mitigate their long-term physical morbidity. Limited evidence of dyadic interdependence between patients’ and caregivers’ physical and mental health trajectories suggests future studies are warranted to identify psychosocial and medical characteristics moderating the relations between patients’ and caregivers’ health.     

Book reviews and books received

Helping interventions John Heron: Helping the Client: a Creative Practical Guide. London: Sage, 1990. £9.95.

A person-centred perspective on school counselling John McGuiness: A Whole School Approach to Pastoral Care. London: Kogan Page, 1989. £8.95.

How to relate effectively Richard Nelson-Jones: Human Relationship Skills (2nd edition). London: Cassell, 1990. £11.95.

Ripe for research? Dave Mearns and Windy Dryden: Experiences of Counselling in Action. London: Sage, 1989. £9.95.

Issues in action Windy Dryden (ed.): Key Issues for Counselling in Action. London: Sage, 1989. £7.95.

The meaning of death Rosemary Dinnage: The Ruffian on the Stair: Reflections on Death. London: Viking, 1990. £14.99.

The empty cradle Irving G. Leon: When a Baby Dies: Psychotherapy for Pregnancy and Newborn Loss. London: Yale University Press, 1990. £20.

Children against themselves Israel Orbach: Children Who Don't Want to Live: Understanding and Treating the Suicidal Child. San Francisco: Jossey-Bass, 1988. £17.95.     

Blood pressure responses of defensive hostile women when facing a real stress task

Objective: This study investigated the importance of the combination of the hostility and defensiveness variables as psychosocial factors that predict the risk of cardiovascular dysfunction. We examined the impact of a stressful situation on blood pressure responses, using a continuous psychophysiological assessment approach.

Design: We measured the evolution of these responses over three experimental phases (adaptation, task and recovery), also considering a minute-by-minute analysis within each phase.

Main Outcome Measures: We used the Cook-Medley Hostility Scale and the Social Desirability Questionnaire to form four groups (high hostility and high defensiveness, high hostility and low defensiveness, low hostility and high defensiveness, and low hostility and low defensiveness).

Results: We expected the group of hostile defensive women to record higher activation (task phase: an academic exam) and slower habituation (recovery phase) compared to the other groups. The results confirmed our hypothesis, as the profile of the hostile defensive individuals was one of constant or sensitization during the task phase, while during the recovery phase those individuals underwent a slow recovery.

Conclusion: Therefore, it can be indicated that the low hostility and low defensive group is the most adaptive, as recorded very little activation in response, and rapid recovery.     

Changes over time in head and neck cancer patients’ and caregivers’ illness perceptions and relationships with quality of life

Objective: This study investigated changes in illness perceptions from diagnosis to six months later in patients with head and neck cancer (HNC) and their caregivers. The study also examined whether discrepancy in patient and caregiver perceptions at diagnosis predicted patient health-related quality of life (HRQL) at six months.

Design: Forty-two patient–caregiver dyads completed the Brief Illness Perception Questionnaire (Brief IPQ) at diagnosis and again six months later. Patients also completed a HRQL questionnaire at both time points. Analyses were performed using the Actor–Partner Interdependence Model.

Main Outcome Measure: Total patient HRQL assessed by the Functional Assessment of Cancer Therapy (FACT-H&N).

Results: Perceptions of emotional impact and illness concern reduced over time in patients and caregivers. Perceptions of treatment control and identity increased in caregivers only. After controlling for the effects of baseline HRQL, and the individual contribution of patient and caregiver illness perceptions, greater discrepancy in perceptions of timeline, personal control, and illness identity among dyads at diagnosis predicted lower patient HRQL at six-month follow-up.

Conclusion: Patients’ and their caregivers’ perceptions of HNC are dynamic over time. Greater discrepancy between patients’ and caregivers’ illness perceptions at diagnosis predict poorer subsequent patient HRQL.     

Book reviews and books received

Practical help for family therapists John Carpenter and Andy Treacher: Marital and Family Therapy. Oxford: Blackwell, 1989. €29.50 (hardback); €9.95 (paperback).

Survival for the guidance teacher W.P. Gothard and E. Goodhew: Guidance and the Changing Curriculum. London: Croom Helm, 1987. €22.50.

Second-class male Michael S. Kimmel (ed.): Changing Men: New Directions in Research on Men and Masculinity. London: Sage, 1987. €35 (hardback); €14.50 (paperback).

Analysing the analyst Rosemary Dinnage: One to One: Experiences of Psychotherapy. London: Viking, 1988. €12.95.

Practical counselling skills revisited Richard Nelson-Jones: Practical Counselling and Helping Skills. London: Cassell, 1988. €7.95.

Snakes and pyramids Jocelyn Chaplin: Feminist Counselling in Action. London: Sage, 1988. €7.95.

The person-centred approach: a key text Dave Mearns and Brian Thome: Person-Centred Counselling in Action. London: Sage, 1988. €7.95.