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Psychosomatics 48:211-216, May-June
doi: 10.1176/appi.psy.48.3.211
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Do Anxiety, Body Image, Social Support and Coping Strategies Predict Survival in Breast Cancer? A Ten-Year Follow-Up Study

Florence Cousson-Gélie, Ph.D., Marilou Bruchon-Schweitzer, Ph.D., Jean Marie Dilhuydy, M.D., and Marthe-Aline Jutand, M.S.

Received May 30, 2006; revised June 20, 2006; accepted July 13, 2006. From the University of Bordeaux, Psychology Laboratory, Bordeaux, France. Send correspondence and reprint requests to Florence Cousson-Gélie, University of Bordeaux 2, Psychology Laboratory EA 3662, IFR 99, Public Health, 3 Ter Place de la Victoire, 33076 Bordeaux CEDEX, France. e-mail: florence.gelie{at}ps.u-bordeaux2.fr
© 2007 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
A longitudinal study enrolled 75 women with primary breast cancer. Before the confirmation of diagnosis, authors measured trait-anxiety and body satisfaction. Three weeks after diagnosis, coping strategies and state-anxiety were evaluated. The number of days of survival was measured 10 years after diagnosis. In Cox proportional-hazards models adjusting for severity of disease and age, high social support and low state-anxiety predicted an increased risk of death from breast cancer. A significant increased risk of death in women with low scores on the Body Image Questionnaire appeared only in the univariate model.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Over the past decades, there has been increasing interest in the association between psychosocial factors and survival after breast cancer diagnosis. Studies have examined a wide range of psychological predictors of survival. Some authors have demonstrated the importance of depression and anxiety in the progression of breast cancer. In two retrospective cohort studies, it was found that women with an unfavorable course of breast cancer had previously experienced depression.1,2 In contrast, high depression and high state-anxiety were associated with longer overall survival in the prospective study of Derogatis et al.,3 but this research included only 35 breast cancer patients. In six other prospective studies, depression was not a significant predictor of relapse.4–8 Spiegel and Giese-Davis9 founded 24 published studies testing whether depression was linked with cancer progression, and 15 reported positive associations. Although state-anxiety was positively linked to survival in two studies, no such association was observed in four others;10 so the evidence for a deleterious effect of depression and anxiety on the course of the disease is not conclusive.

It has also been suggested that coping-strategy traits such as helplessness and hopelessness can predict a poor outcome, whereas "fighting spirit" is associated with longer survival.7,11–15 However, in a 5-year prospective study conducted with 587 breast cancer patients, Watson Laboratories, Inc. et al.16 found that helplessness/hopelessness significantly predicted shorter event-free but not overall survival at 5 years. Fighting spirit had no significant effects on survival. These results were maintained for up to 10 years of follow-up.8 Therefore, consensus is also lacking with regard to coping strategies.

The strongest evidence for a relationship between psychosocial variables and survival has been provided by studies that include a social-support variable. Several qualitative reviews10,17–19 and one metaanalysis20 showed that perception of social support is a significant predictor of favorable prognosis. One recent study21 of 2,835 breast cancer patients found that women with low levels of social integration before breast cancer diagnosis had a 66% increased risk of all-cause mortality and a twofold increased risk of mortality from breast cancer.

Previous studies examining the role of body image among cancer patients have primarily focused on the psychosocial adjustment of women with breast cancer who have undergone mastectomy or lumpectomy.22 Surprisingly, little is known about predictive value of body image on survival.

The general lack of agreement could be due to the fact that most of the studies exploring the effects of several psychosocial factors on survival of breast cancer were not drawn from a clear theoretical model. We therefore decided to study, with an integrative model, the link between psychological factors and duration of survival. The model is based on Lazarus and Folkman’s transactional stress model.23 Having breast cancer is clearly very stressful, so women develop reactions and strategies to cope with the situation. According to our transactional model, adjustment strategies developed by patients to cope with their disease and treatment can mediate the effects of the antecedents on the criterion. The objective was to test the relationships between some psychosocial variables (personality traits; perceptivo-cognitive, emotional, and behavioral processes) and survival after breast cancer diagnosis.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
Women with non-metastatic breast cancer (Stage II and III) who consulted an oncologist at the Institute Bergonié in Bordeaux between January 1993 and January 1995 were invited to participate in the study. The inclusion criteria were age (18 to 70 years old), having suspected breast cancer, being treated with neo-adjuvant chemotherapy, and undergoing a local/regional treatment (surgery and radiotherapy). Patients with metastases, recurrence, or other cancers were excluded. The selected patients were asked to take part in a study assessing the emotional and psychological impact of cancer. Seventy-nine patients accepted participation; four patients with non-invasive breast cancer were excluded. Finally, 75 patients were included at baseline.

Procedure
Variables of the study were assessed three times:
The First Stage (T1) was before disclosure of diagnosis and treatment.

Evaluation of Antecedents
Sociodemographic antecedents and stable personality characteristics were estimated by an interview and questionnaires. The Body Image Questionnaire (BIQ),24 validated in a French sample, assesses perceptions, feelings, and attitudes regarding one’s body in terms of satisfaction/dissatisfaction. A factorial analysis of the responses of our 75 breast cancer patients yielded one axis, accounting for 26.4% of total variance, identified as General Body Satisfaction/Dissatisfaction.25 The State–Trait Anxiety Inventory, Form Y26,27 evaluated anxiety as a personality trait. Medical data were collected by the nursing staff: TNM stage, that is, classification evaluating primary tumor size (T), lymph-node invasion (N), and presence or absence of distant metastases (M) and hormonal dependence (presence of progesterone and estrogen receptors) were also reported.

The Second Stage (T2) was 3 weeks after the diagnosis and treatment plan were determined for the patient.

Evaluation of Mediators
The processes describing the way in which the patients reacted to their disease (perceived social support, coping strategies, and anxiety) were evaluated by three questionnaires: 1) the Social Support Scale28,29 measures perceived availability (number of people the individual thinks he or she can count on, if necessary) and satisfaction with perceived social support; 2) the Ways-of-Coping Checklist–R (WCC–R) a revised 27-item version of the WCC of Lazarus and Folkman,30 assesses three coping strategies (problem-focused coping, emotion-focused coping, and seeking social support). This French adaptation, validated in 468 subjects, established its good validity, reliability, and internal consistency;31 and 3) the State–Trait Anxiety Inventory, Form Y,26 validated in French samples by Bruchon-Schweitzer and Paulhan,27 assesses state-anxiety. In our study, coping responses were measured by the WCC–R, whereas Watson et al.8,16 evaluated coping responses by use of the Mental Adjustment to Cancer (MAC) scale.

The Third Stage (T3) was 10 years after diagnosis and treatment.

Evaluation of Criterion
Survival was defined by the number of days between the date of diagnosis and death. Data were collected from medical records.

Statistical Analysis
Survival analyses were calculated by use of the Cox proportional-hazards regression model, calculating the crude hazard ratio (HR) for each individual psychological measure and the HR adjusted for tumor size, number of positive lymph nodes, estrogen-receptor status, and age. So, in the multivariate regression analyses, one psychological variable and four control variables were included. HR values >1 are presented; these indicate a greater risk of mortality (lower survival time). An HR <1 indicates that a 1-unit increase in the predictor variable is associated with a reduced risk of mortality. For patients still alive, survival was calculated from the date of diagnosis until last follow-up (10 years), and these patients were censored.

The Body Image Questionnaire (BIQ) was dichotomized with a standard cut-off to define cases. The cut-off was the value of the mean plus one standard deviation (SD) for each individual score, as defined in the French validation of the BIQ.24 For the WCC–R scale, we adopted the procedure of Greer et al.12 and Watson Laboratories, Inc. et al.16 for the MAC (Mental Adjustment to Cancer) scale, which classified each patient into three categories according to her predominant scores in problem-focused coping, emotion-focused coping, or seeking social support (standardized z scores). A patient was classified as having no predominant response when all her standardized scores were less than 0.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
The study group consisted of 75 breast cancer patients (Table 1). The mean age of the women at the starting-point of the study was 48 years (SD: 9.8). A total of 43 patients (57.3%) had died during the 10 years of follow-up, 37 of breast cancer. In the remaining 6 patients, the cause of death could not be specified by the hospital, general practitioner, or cancer registry records. Therefore, to analyze survival at 10 years, we took 69 patients into account: 32 alive (46.4%) and 37 (53.6%) having died of breast cancer.


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TABLE 1. Demographic and Biomedical Status at Enrollment (N=75)



Table 2 contains the crude and adjusted HRs of personality traits, sociodemographic, and medical antecedents for overall survival at 10 years. A high score on the BIQ was significantly associated with a reduced risk of mortality in univariate analysis (crude HR: 0.50; 95% confidence interval [CI]: 0.26–0.96), but this became non-significant after adjustment for prognostic factors (adjusted HR: 0.79; 95% CI: 0.39–1.61). An increased HR was found for widowed or divorced women (crude HR: 11.07; 95% CI: 2.14–57.20), but this effect became non-significant in multivariate analysis (adjusted HR: 2.93; 95% CI: 0.96–8.93). None of the biological parameters (TNM and age) was significantly associated with length of survival. Only two psychosocial variables appeared as predictors of survival (Table 3). A high score on the Availability of Social Support quantity subscale of the SSQ–6 was associated with increased risk of death, but only after adjustment for medical variables (adjusted HR: 1.04; 95% CI: 1.01–1.07). A low state-anxiety score was associated with lower survival (adjusted HR: 0.97; 95% CI: 0.94–0.99). We observed no statistically significant effects of perceived stress, perceived control, coping strategies, and social support satisfaction on survival. No significant association was found between the predominant coping response on the WCC–R scale and overall survival.


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TABLE 2. Results of Cox Proportional-Hazards Regression Analysis for Personality Traits, Medical and Sociodemographic Antecedents, and Overall Survival at 10 Years




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TABLE 3. Results of Cox Proportional-Hazards Regression Analysis for Psychosocial Variables and Overall Survival at 10 Years




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
This study investigated the effects of several psychosocial variables on survival after a diagnosis of breast cancer. Like the data of Watson Laboratories, Inc. et al.,8,16 the present findings do not corroborate those reported by Greer et al.12 We observed no effect of coping responses on survival. This is interesting because we used another scale to evaluate coping strategies1 and observed no survival difference associated with high WCC–R focused problem-coping scores.

Body satisfaction before the disclosure of diagnosis was associated with longer survival at 10 years. Body image has proven to be linked to quality of life in studies comparing mastectomy versus breast-conserving treatments.32 Several authors, such as Carver et al.,33 have suggested that patients adjust less well to breast cancer if they are greatly concerned about either aspect of their body image. To our knowledge, no research had studied the effects of body-image on survival. However, this effect became nonsignificant after adjustment for known prognostic factors in our study, so this result should be interpreted cautiously.

We found evidence for state-anxiety being predictive of survival. In contrast, Watson Laboratories, Inc. et al.8,16 found that high helplessness/hopelessness subscale scores on the MAC scale increased the risk of death. In our study, anxiety was associated with longer survival. These discrepancies could be due to the fact that state-anxiety measured in our study included negative affectivity (fears) but not feelings of helplessness. The STAI–Y state scale measures the intensity of present anxious reactions. Low state-anxiety scores indicate that negative affects are absent or unexpressed. Several studies have established that restriction of emotion in newly diagnosed breast cancer patients predicts poor outcome.34–37 Weihs et al.38 also found that restriction of emotion predicted higher mortality in recurrent breast cancer.

Surprisingly, high SSQ–6 Availability subscale scores were associated with an increased risk of death, whereas social support has been reported elsewhere to reduce the risk of mortality.4,12,38–45 Only the availability of support (friends, relatives) was significantly related to survival when controlling for prognostic factors, whereas satisfaction with social support appeared unrelated to survival. Patients used coping strategies such as the reduction of negative affects (state-anxiety) and self-reassurance such as awareness of the availability of social support.

This study only had sufficient power to detect large HRs. We were unable to establish any predictive effect of most of the coping strategies, and the effect of satisfaction with social support on survival has not been established by our study, a finding coherent with a 6-year Italian follow-up study.46 Even reasonably large effects may have been impossible to detect because of the limited power of the study. Further studies using the same variables need to be undertaken on similar subjects but with larger samples and repeated measurements of state-anxiety, coping, and social support, because these variables could change over time.

The present findings suggest that breast cancer patients who minimize their negative affects (low state-anxiety, high perceived availability of social support) have poorer survival. Suppression of negative emotions induced by a stressor might be associated with immunological changes, which, in turn, speed up the evolution of the disease. This lends weight to the Type C personality hypothesis, which includes the notion of difficulty in expressing negative emotions,47 even though the putative link between Type C personality and survival has not been demonstrated by others.48 Nevertheless, the hypothesis that increased physiological activity associated with emotional suppression to cope with stress might increase risk of death from breast cancer has received some support.41 Even so, the mechanisms that link psychosocial factors with survival remain unclear at present49 because of the difficulty in generalizing the results of in-vitro immunological tests to real-life situations and the rarity of prospective multidisciplinary survival studies with sufficiently large samples.

The fact that psychosocial factors could prolong survival after breast cancer could be useful for psychosocial interventions conducted with breast cancer patients, especially with regard to the expression of negative affects.


  ACKNOWLEDGMENTS

 
Special thanks go to all the patients who participated in the study. We also thank all the staff of the Institut Bergonié and Drs. Michel Durand and Louis Mauriac for their special cooperation, and Estelle Beauvallet and Loréna Matthey for assistance with data collection.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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