Download Coping responses following breast cancer diagnosis predict

PSYCHO-ONCOLOGY
Psycho-Oncology 13: 235–247 (2004)
Published online 3 June 2003 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.739
COPING RESPONSES FOLLOWING BREAST
CANCER DIAGNOSIS PREDICT
PSYCHOLOGICAL ADJUSTMENT
THREE YEARS LATER
a
THOMAS F. HACKa,b,*, and LESLEY F. DEGNERa
Faculty of Nursing, University of Manitoba, Canada
b
Department of Clinical Health Psychology, Faculty of Medicine, University of Manitoba, Canada
SUMMARY
The relationship between coping responses and psychological adjustment to a breast cancer diagnosis is well
documented for time periods close to diagnosis. The purpose of the present study was to assess the long term
association between these two variables. Fifty-five women completed measures of coping response, decisional
control, frustration expression, and psychological adjustment within six months of receiving their breast cancer
diagnosis. These women were contacted three years later and their psychological adjustment}as measured by the
profile of mood states (POMS)}was reassessed. Univariate and multivariate analyses were performed. The results
showed that women who were depressed at time of treatment planning, and who responded to their cancer diagnosis
with cognitive avoidance, i.e. acceptance/resignation, had significantly worse psychological adjustment three years
later. Poor adjustment was significantly associated with cognitive avoidance and minimal use of approach-based
coping responses. The findings suggest that women who respond to their breast cancer diagnosis with passive
acceptance and resignation are at significant risk for poor long term psychological adjustment. Psychological
interventions for these women should address cognitive avoidance, with the aim of fostering approach-based coping
and positive well-being. Copyright # 2003 John Wiley & Sons, Ltd.
INTRODUCTION
To be diagnosed with breast cancer is among the
most devastating events that can befall a woman.
News that one has a life-threatening illness can
instill fears of impending death, and recurrence
fears can linger for years following breast cancer
surgery. The breast cancer illness trajectory poses
several challenges for women: adjusting to the
initial news of having breast cancer; planning and
recovering from any surgical management of the
disease; questioning the most appropriate course
of adjuvant therapy; overcoming the side effects of
treatment; awaiting word of being disease-free or
*Correspondence to: St. Boniface Hospital Research Centre,
351 Tache Avenue, Winnipeg, Manitoba, Canada R2H 2A6.
E-mail: [email protected]
Copyright # 2003 John Wiley & Sons, Ltd.
having a recurrence; and preparing for death in the
case of progressive disease (Payne et al., 1996).
A breast cancer diagnosis is frequently associated with psychological reactions of anxiety and
depression. A recent prevalence survey of 1249
women newly diagnosed with breast cancer found
that 32.8% had psychological distress (Zabora
et al., 2001). The first few months following receipt
of a breast cancer diagnosis have long been known
to be particularly challenging for women (Weisman and Worden, 1976), as this period of time is
one during which women adjust to their diagnosis,
the loss of breast tissue, and any side effects of
adjuvant therapy.
Early theoretical models identified successful
adaptation as a primarily cognitive process
marked by establishing personal meaning out of
the illness (Moos and Schaefer, 1986; Taylor,
1983), gaining a sense of mastery (Moos and
Schaefer, 1986; Taylor, 1983), and enhancing
Received 12 October 2002
Accepted 11 April 2003
236
T.F. HACK AND L.F. DEGNER
self-esteem (Taylor, 1983). Proper regulation of
affect, appraising one’s plight realistically, and
having a supportive social network were also
identified as aspects of adaptive coping (Moos
and Schaefer, 1986). More recently, the SocialCognitive Transition model of adjustment to
cancer (Brennan, 2001) has been put forward.
According to this model, adjustment is an ongoing
process of learning from, and adapting to, the
many changes that an individual faces as a result
of living with, and receiving treatment for, cancer.
The degree of adjustment depends on the combined effect of coping responses, social support,
and cognitive appraisal of the cancer experience.
Empirical studies have identified several variables
found to be significantly related to positive or
negative psychological adjustment to cancer. The
following variables have been shown to be significantly related to positive psychological adjustment: high internal locus of control (Burgess et al.,
1988), perceived control (Taylor et al., 1984); confronting the disease (Weisman and Worden, 1976;
Burgess et al., 1988); problem-focused enga-gement
coping (Epping-Jordan et al., 1999); hopefulness
(Herth, 1989); dispositional optimism (EppingJordan et al., 1999); a fighting spirit (Classen et al.,
1996; Schnoll et al., 1998); emotional expression
(Stanton et al., 2000), acceptance (Carver et al.,
1993); active acceptance at diagnosis (Stanton et al.,
2002), and humor (Carver et al., 1993). Variables
found to be significantly associated with poor
adjustment include: emotion-focused coping (BenZur et al., 2001; Epping-Jordan et al., 1999), emotional suppression (Weisman and Worden, 1976;
Classen et al., 1996); social withdrawal (Weisman
and Worden, 1976); fatalism (Schnoll et al., 1998);
anxious preoccupation (Schnoll et al., 1998); and
helplessness (Burgess et al., 1988; Schnoll et al.,
1998). Avoidance-based coping responses are associated with increased psychological distress
(McCaul et al., 1999; Shapiro et al., 1997; Stanton
and Snider, 1993), and have been found to predict
fear of cancer recurrence among women with breast
cancer across the first year post-diagnosis (Stanton
et al., 2002).
The purpose of the present study was to follow a
group of women newly diagnosed with early stage
breast cancer over time, and to assess the relationship between the use of avoidance and approach
coping responses around the time of adjuvant
treatment planning (baseline), and psychological
adjustment three years later (follow-up). At baseline, a cluster analysis of coping responses
Copyright # 2003 John Wiley & Sons, Ltd.
produced three statistically distinct coping clusters, characterized by (1) low avoidance/moderate
approach coping, (2) moderate avoidance/high
approach coping, and (3) high avoidance/low
approach coping. Women from the low avoidance
coping cluster had significantly better psychological adjustment than women from the other two
clusters (Hack and Degner, 1999). For the present
study, it was hypothesized that the three distinct
coping clusters would continue to differ significantly after three years with respect to psychological adjustment, in accordance with the baseline
findings. The second hypothesis was that avoidance coping at time of diagnosis is a significant
predictor of psychological adjustment three years
later. To address this hypothesis, a multiple
regression analysis of all patients was performed,
regardless of cluster, controlling for demographic/
illness factors and baseline levels of psychological
adjustment.
In recent years, increasing empirical attention
has been paid to the role of emotional expressivity
in successful adjustment to cancer. It has been
documented that expression of emotion is significantly associated with poor adjustment (Compas
et al., 1999), and that negative emotion, in
particular, is significantly related to cancer progression (Baltrusch et al., 1988; Reynolds et al.,
2000; Temoshok, 1987). Other research findings
have suggested the opposite with respect to
adjustment; that a fighting spirit (Classen et al.,
1996) is beneficial while emotional suppression
(Weisman and Worden, 1976; Classen et al., 1996)
hampers the adjustment process. The manner by
which emotional expressivity has been conceptualized and measured across studies may account for
some of the discrepant findings. This is suggested
by the finding that psychological adjustment is
positively related to emotional ‘expression’ (e.g. ‘I
take time to express my emotions’), yet inversely
related to emotional ‘processing’ (e.g. ‘I take time
to figure out what I’m really feeling’) (Stanton
et al., 2000). In another study, emotion-focused
engagement coping and emotion-focused disengagement were both significant predictors of
greater emotional distress (Epping-Jordan et al.,
1999). In the current study, as part of the analysis
of the first hypothesis, patient reports of expression of negative emotion were assessed for crosscluster differences three years post-diagnosis.
Efforts to enhance the coping effort of women
diagnosed with breast cancer have begun, over the
past decade, to address the degree of involvement
Psycho-Oncology 13: 235–247 (2004)
COPING RESPONSES AND PSYCHOLOGICAL ADJUSTMENT
that women have, or want to have, in treatment
decision making. Despite inconsistencies across
studies in this area, it may be concluded that a
significant proportion of women prefer to be
actively involved in treatment decision making
and these women are significantly younger (Blanchard et al., 1988; Degner and Russell, 1988;
Degner and Sloan, 1992), and more highly
educated (Brandt, 1991; Degner and Sloan, 1992;
Hack et al., 1994; Cassileth et al., 1980) than
women who prefer passive involvement. It has
been shown that women with breast cancer who
are given an opportunity to choose their surgical
treatment have less hopelessness, avoidance, fatalism, and anxiety than women whose cancer
necessitates having a mastectomy (Deadman
et al., 2001). The results of this study also showed
that women who were invited to participate in the
decision making process and who were given
responsibility for making their treatment choice
had significantly less depression and more fighting
spirit than women who were invited to participate
but were given no responsibility for the choice of
treatment. Women who indicate at time of
diagnosis that they prefer active involvement in
treatment decision making have been shown to use
significantly fewer cognitive avoidance coping
responses, and to have significantly higher psychological adjustment, than women who prefer
passive involvement (Hack and Degner, 1999). In
the present study, patients’ preferred degree of
involvement in decision making was examined as a
predictor variable in the statistical analysis of the
second hypothesis.
237
and four were eliminated for having incomplete
data. By excluding other cancer disease sites, and
interviewing only those women with Stage I or II
tumors, the sample was standardized with respect
to disease type, illness severity, and prognosis. The
average age of the women was 55.3 years
ðS:D: ¼ 10:1Þ. Nearly half (49.1%) of the women
acquired post-secondary education, with 16.4%
having completed only high school, and 34.5% not
having a high school diploma. Twenty percent of
the women received a modified radical mastectomy
while 80% received a partial mastectomy. While
69.1% of the women received only radiation
therapy as part of their adjuvant treatment regimen, 23.6% received either chemotherapy alone or
both radiation therapy and chemotherapy, and
7.3% received only hormone therapy. All women
were able to read and speak English, and were
discerned to be free of any cognitive impairment
that would disable them from providing informed
consent.
All women were between 1.5 to 6 months postdiagnosis at baseline (mean=90.3 days,
S.D.=18.4 days). The minimum time inclusion
criterion of 1.5 months post-diagnosis was
adopted to ensure that all women had commenced
their adjuvant treatment regimens, and 6 months
post-diagnosis was established as the maximum
time inclusion criterion to further enhance the
homogeneity of the sample. The recruitment goal
was to sample women in the few months following
diagnosis; a period of time when psychosocial
distress is pronounced for many patients, and the
use of particular coping responses is potentially
critical to the successful management of emotional
reactions to illness and treatment.
METHOD
Study Design
Participants
The sample was comprised of 55 women
diagnosed with Stage I ðn ¼ 34Þ or II ðn ¼ 21Þ
breast cancer, and consecutively accrued from two
tertiary oncology treatment referral clinics in
Winnipeg, Manitoba, Canada. These women were
part of the original sample of 70 women who had
participated in the baseline study of coping
response and psychological adjustment (Hack
and Degner, 1999). Of the 15 women from the
baseline sample who did not participate in the
three-year follow-up study, four had died, two
chose not to participate, five could not be located,
Copyright # 2003 John Wiley & Sons, Ltd.
The study protocol was approved by the Human
Subjects Ethical Review Committee at the University of Manitoba. All women provided informed, written consent to participate in the study.
Data was obtained by clinical nurse researchers
who were not involved in the clinical care of the
patient sample. A nurse researcher called each
patient via telephone at approximately three years
following her involvement in the baseline study. If
the patient was willing to participate in the
follow-up study, an appointment was scheduled.
At the appointment, the research nurse began by
obtaining informed consent and reviewing the
Psycho-Oncology 13: 235–247 (2004)
238
T.F. HACK AND L.F. DEGNER
sociodemographic, illness, and treatment information obtained three years earlier so that changes
and additions could be made. The nurse researcher
then administered the following measures:
Coping responses inventory. Coping effort was
measured at baseline using the coping responses
inventory (CRI: Moos, 1988): a 48-item inventory
that measures cognitive and behavioral coping
according to approach (i.e. logical analysis,
positive reappraisal, social support, problemsolving), and avoidance (i.e. cognitive avoidance,
resigned acceptance, alternative rewards, and
emotional discharge) coping responses. The CRI
subscales are reported to have high internal
consistency, to be moderately intercorrelated,
and only minimally associated with age, education,
and ethnicity (Moos, 1997). There is growing use
of cluster analytic techniques in studies of the
coping responses (Hack and Degner, 1999; Nelson
et al., 1994; Shapiro et al., 1997; Shapiro et al.,
1994) and quality of life (Nagel et al., 2001) of
women with breast cancer. For the present study,
Cronbach’s alpha was 0.66 for the avoidance
subscales and 0.74 for the approach subscales.
Profile of mood states. Psychological adjustment was measured at baseline and at follow-up
using the profile of mood states (POMS) (McNair
et al., 1971); a 65-item measure of general
emotional disturbance. The measure is comprised
of seven subscales, including depression, anxiety,
confusion, fatigue, anger, vigor, and friendliness.
Indication of positive and negative adjustment to
illness is obtained by asking patients to rate each
item on a five-point scale (0=Not at all; 4=Extremely) with respect to how they have been feeling
over the past week. A true POMS score is derived
by subtracting the vigor subscale from the sum of
the five negative subscales; friendliness scale is
excluded. To more clearly differentiate between
positive and negative affect, a POMS negative
score was calculated by summing the five negative
subscales (Reddon et al., 1985). Likewise, the two
positive subscales were summed to yield a POMS
positive score. The POMS has been used frequently over the past ten years to measure
psychological adjustment in women with breast
cancer (Andrykowski et al., 1996; Carver et al.,
1993; Classen et al., 1996; Cruess et al., 2000;
Cunningham et al., 1999; Edelman et al., 1999;
Edmonds et al., 1998; Fobair et al., 2001; Ganz
Copyright # 2003 John Wiley & Sons, Ltd.
et al., 1996; Koopman et al., 1998; McCaul et al.,
1999; Spiegel et al., 1999; Stanton et al., 2000;
Stanton et al., 2002). For this sample, Cronbach’s
alphas at follow-up ranged from 0.34 (anxiety) to
0.71 (friendliness) for the seven POMS subscales.
Patient preference for treatment decision control. Patients’ preferences for control over treatment decision making were obtained at baseline
using a well-validated card sort technique (Degner
et al., 1997; Degner and Russell, 1988; Degner and
Sloan, 1992) whereby patients are provided with
five cards comprised of written vignettes and an
illustrative drawing, and are asked to sort the
cards according to their preferred choices. The
vignettes vary in the degree of treatment decision
making control preferred by the patient, and the
final order of the cards indicates the degree to
which patients wish to relinquish (two cards:
‘I prefer to leave all decisions regarding my treatment to my doctor’; ‘I prefer that my doctor makes
the final decision about which treatment will be
used, but seriously considers my opinion’), share
(one card: ‘I prefer that me doctor and I share
responsibility for deciding which treatment is best
for me’), or retain (two cards: ‘I prefer to make the
final selection of my treatment after seriously
considering my doctor’s opinion’; ‘I prefer to make
the final selection about which treatment I will
receive’) control over treatment decision making.
At baseline (Time 1), the 205 women were asked to
consider their involvement in the decision about
surgical treatment for their breast cancer. The five
cards were then presented in pairs, and the women
were asked to specify which of the two cards was
closest to their preferred role. The order of
presentation of the cards was fixed (Card B,
followed by D, C, A, and E) so that order effects
would be held constant across all patients. The
women compared two cards at a time toward
developing their unique preference order.
Expression of negative emotion. The extent to
which patients tend to express or suppress feelings
of frustration was measured by administering the
anger expression inventory of the self-rating
questionnaire (Spielberger, 1988) at baseline and
at follow-up. Scores are generated for three subscales}suppressed, vented, and controlled}and a
value for expressed frustration is generated by
subtracting the controlled subscale score from the
sum of the suppressed and vented subscales.
Psycho-Oncology 13: 235–247 (2004)
COPING RESPONSES AND PSYCHOLOGICAL ADJUSTMENT
Although the instrument is said to measure anger
expression, the questionnaire items suggest that
the expression of negative emotion in general,
including anger, is being assessed.
Statistical analysis
SAS software, Version 8.1 (SAS Institute, Inc,
Cary, NC) was used to generate descriptive
statistics and to perform statistical calculations.
A cluster analysis was used on the baseline data to
generate distinct coping profiles among the women, based on their responses to the CRI. Ward’s
(Ward, 1963) method of minimum-variance clustering was used, with the squared Euclidean
distance as the metric. This method is popular
and commonly recommended as the best available
(Blashfield, 1976; Edelbrock, 1979; Edelbrock and
McLaughlin, 1980; Kuiper and Fisher, 1975;
Milligan, 1980; Milligan and Isaac, 1980; Mojena,
1977; Overall et al., 1993).
The cluster analysis of the baseline data showed
that the three-cluster solution provided the best fit
for the data. The means of the coping subscales for
these three coping clusters were compared and a
verbal descriptor was added to each cluster as
follows: Cluster 1}low cognitive avoidance and
moderate approach (low avoidance); Cluster
2}high cognitive avoidance and low approach
(high avoidance); and Cluster 3}moderate cognitive avoidance and high approach (high general
coping). It is these three clusters of patients that
were assessed three years later for significant
differences on the outcome variables.
Differences in POMS scores and scores on the
anger expression inventory between Time 1 (baseline) and Time 2 (three years later) were assessed
using paired t-tests. The statistical relationship
between coping style at baseline and psychological
adjustment three years later was assessed in two
ways. First, each patient was assigned to their
baseline cluster and the difference in the follow-up
POMS scores across the three clusters were tested
using analyses of variance (ANOVA). Tukey’s
Honestly Significant Difference (HSD) procedure
was applied to each significant main effect. Second,
the coping data for all patients were collapsed and
examined using regression analyses. Collapsing the
data allowed for a more pure, refined test of the
hypothesis that avoidance coping at baseline is
associated with poor long term psychological
adjustment. Hierarchical regression analyses were
Copyright # 2003 John Wiley & Sons, Ltd.
239
performed because they allow for the systematic
introduction of categories of independent variables
to be assessed, after statistically eliminating
variance in the dependent variable that is attributable to demographic and illness variables. The
following five demographic/illness variables were
forced into all regressions in the first entry step:
Age; education; tumor stage; type of surgery; and
adjuvant treatment.
In model 1 of the hierarchical regression
building procedure, the eight baseline variables
for the CRI (i.e. logical analysis, positive reappraisal, social support, problem-solving, cognitive
avoidance, resigned acceptance, alternative rewards, and emotional discharge) were added to
the forced demographic/illness variables. In model
2, the seven subscales for the POMS were added to
the forced demographic/illness variables. In model
3, the preferred role in treatment decision making
were added to the forced demographic/illness
variables. For models 1, 2, and 3, a significance
level of a ¼ 0:15 was used. In model 4, significant
variables from models 1, 2, and 3 were entered
after forcing the demographic/illness variables.
Variables that were retained in the model satisfied
the significance criterion of a ¼ 0:05.
RESULTS
The mean duration from the baseline to follow-up
interview was 1600 days, or 3 years, 2 months, and
4 days (S.D.=81.8 days). Paired t-tests comparing
the baseline POMS and anger expression inventory subscales and total scores with their respective
three-year follow-up scores showed no significant
changes over this time period. The three-year
follow-up means and standard deviations for each
of the subscales of the POMS and the Anger
Expression Inventory are presented in Table 1 for
each baseline coping cluster. Three of the seven
POMS subscales showed statistically significant
differences between clusters. Patients in the low
avoidance cluster had significantly lower anxiety,
F(2,52)=3.80, p50.05, than patients in the high
general coping cluster. Patients in the high
avoidance cluster had significantly lower friendliness, F(2,52)=7.37, p50.01, and lower vigor,
F(2,52)=4.69, p50.05, scores than patients in
the high general coping cluster. Patients in the high
avoidance cluster also had significantly lower
friendliness, F(2,52)=7.37, p50.01, scores than
Psycho-Oncology 13: 235–247 (2004)
240
T.F. HACK AND L.F. DEGNER
Table 1. Three-year follow-up cluster means and standard deviations for psychological adjustment and frustration expression
Variable
Cluster 1:
Low avoidance ðn ¼ 20Þ
Cluster 2:
High avoidance ðn ¼ 17Þ
Cluster 3:
High general coping
(moderate to high avoidance
and approach) ðn ¼ 18Þ
Mean
S.D.
Mean
S.D.
Mean
S.D.
3.25
4.90
5.59b
3.90
6.35
17.40
19.48a
6.58b
23.98
36.88a
3.54
2.38
2.73
3.34
5.79
5.93
2.70
16.28
13.44
8.14
10.18
6.82
8.94
7.35
8.88
13.18b
16.12b
29.00a
42.18
29.29b
11.49
4.33
5.55
6.75
6.57
4.59
4.48
33.68
30.99
8.16
7.22
6.39
9.28a
7.72
6.39
18.72a
20.61a
18.28
37.00
39.33a
10.29
3.36
5.18
7.04
4.73
6.03
3.53
28.45
25.07
9.11
Anger expression inventory
Suppressed
13.90
Vented
11.95
Controlled
24.15
Expressed
17.70
3.81
2.19
3.23
5.21
16.94
12.00
21.65
23.29
4.13
2.94
4.23
7.74
15.33
12.33
24.61
19.06
3.66
2.85
4.47
8.35
POMS
Depression
Confusion
Anxiety*
Anger
Fatigue
Vigor*
Friendliness**
True POMS*
POMS neg.
POMS pos.**
Significant inter-cluster differences using Tukey’s-HSD procedure (a>b). See text for description of cluster differences.
*p50.05.
**p50.01.
the low avoidance cluster patients. Negative affect,
as measured by the true POMS total score, was
significantly higher for patients in the high
avoidance cluster in comparison to the low
avoidance cluster, F(2,52)=2.92, p50.05. The
POMS positive index also reached statistical
significance, with high avoidance cluster patients
having less positive affect than patients in either of
the remaining clusters, F(2,52)=6.65, p50.01. No
statistically significant differences between clusters
were found for any of the subscales of the anger
expression inventory.
Patients from all three clusters were collapsed to
enable hierarchical regression analyses to be
performed. Table 2 shows the results for all the
model 1 regressions, i.e. the regressions for each
POMS subscale and true POMS score entered as
dependent variables, and after entering the control
variables as the first entry step and the eight CRI
subscales as the second entry step. One of the two
cognitive avoidance subscales, namely acceptance/
resignation, was significantly associated with
POMS depression, confusion, anxiety, fatigue,
vigor, friendliness, and true POMS score. The
logical analysis CRI subscale was a significant
Copyright # 2003 John Wiley & Sons, Ltd.
predictor of POMS anxiety and friendliness, the
emotional discharge CRI subscale was a significant predictor of POMS anger and friendliness,
the problem solving subscale CRI subscale was
significantly related to POMS vigor and friendliness, and the social support and positive reappraisal CRI subscales were significantly related to
POMS friendliness. Table 3 shows the regressions
for model 2, in which baseline scores for the seven
POMS subscales were independently entered as
predictors of psychological adjustment (POMS)
three years post-baseline, after forcing the control
variables in the first entry step. Baseline depression
was a significant predictor of follow-up depression, confusion, anxiety, and anger. Baseline vigor
was a significant predictor of follow-up depression, confusion, and vigor. Confusion at baseline
was significantly related to confusion at follow-up.
Baseline anxiety was significantly associated with
follow-up confusion. Baseline fatigue was an
independent predictor of follow-up fatigue and
true POMS score, while baseline friendliness was
significantly associated with follow-up friendliness.
The regressions for model 3, in which the degree
of patients’ preferred involvement in treatment
Psycho-Oncology 13: 235–247 (2004)
241
COPING RESPONSES AND PSYCHOLOGICAL ADJUSTMENT
Table 2. Multiple regression analyses of follow-up psychological
adjustment (POMS) by baseline coping responses (CRI)*
Dependent variable
Depression
Acceptance/resignation
Confusion
Acceptance/resignation
Anxiety
Acceptance/resignation
Anger
Emotional discharge
Fatigue
Acceptance/resignation
Vigor
Acceptance/resignation
Problem solving
Friendliness
Problem solving
Acceptance/resignation
True POMS total
Acceptance/resignation
POMS negative
Acceptance/resignation
POMS positive
Problem solving
Acceptance/resignation
DR2 Cumulative Beta
R2
weight
p
Dependent
variable
0.167 0.286
0.421
0.002
0.124 0.268
0.363
0.006
0.108 0.266
0.332
0.011
0.127 0.185
0.368
0.009
0.064 0.335
0.260
0.037
0.121 0.261
0.060 0.321
$0.295
0.262
0.025
0.047
0.050 0.228
0.106 0.334
0.294
$0.319
0.042
0.020
0.182 0.361
0.439 50.001
0.157 0.321
0.408
0.002
0.085 0.259
0.131 0.390
0.312
$0.297
0.014
0.018
*The following variables were forced into the analysis of each
dependent variable as the initial entry step: Age; education; tumor
stage; type of surgery; and adjuvant treatment. The following CRI
variables were entered: Cognitive avoidance, acceptance/resignation, alternative rewards, emotional discharge, logical analysis,
positive reappraisal, social support, and problem solving.
decision making at baseline was entered as a
predictor of psychological adjustment at followup, is displayed as Table 4. After forcing the
control variables, decisional control preference
was significantly predictive of follow-up depression, anxiety, anger, and true POMS total score.
Patients who, at baseline, preferred to defer the
selection of a treatment decision their physicians
had significantly worse adjustment three years
later.
The significant variables of models 1, 2, and 3
were entered into the final predictive model}model 4}after entering the control variables in the
first step. As shown in Table 5, overall psychological adjustment at follow-up, as indicated by true
POMS score, was significantly related to baseline
coping responses of passive resignation and
acceptance. Baseline passivity and resigned acceptance was the most frequent predictor, being
Copyright # 2003 John Wiley & Sons, Ltd.
Table 3. Multiple regression analyses of follow-up psychological
adjustment (POMS) by baseline psychological adjustment
(POMS)*
Depression
Depression
Confusion
Confusion
Anxiety
Anxiety
Depression
Anger
Depression
Fatigue
ns.
Vigor
ns.
Friendliness
Friendliness
True POMS total
Depression
POMS negative
Depression
POMS positive
Friendly
DR2
Cumulative
R2
Beta
weight
p
0.262
0.382
0.647
50.001
0.045
0.100
0.190
0.290
0.444
0.519
0.007
0.017
0.192
0.351
0.467
50.001
0.181
0.239
0.453
0.001
0.232
0.410
0.494
50.001
0.173
0.351
0.442
50.001
0.182
0.346
0.455
50.001
0.092
0.266
0.311
0.018
*The following variables were forced into the analysis of each
dependent variable as the initial entry step: Age; education; tumor
stage; type of surgery; and adjuvant treatment. The following
POMS variables were entered: Depression, confusion, anxiety,
anger, fatigue, vigor, and friendliness.
significantly associated with five of the seven
POMS subscales: depression, confusion, fatigue,
vigor, and friendliness. Two other CRI baseline
subscales were significant predictors of follow-up
psychological adjustment: (a) Emotional discharge
was significantly related to POMS anger, and
(b) problem solving was significantly associated
with POMS vigor. POMS depression, confusion,
and friendliness were each significantly predicted
by baseline levels of depression, confusion, and
friendliness, respectively. POMS depression at
baseline was, in addition, a significant predictor
of POMS anxiety, anger, and true POMS total
score at follow-up. Baseline decisional control
preference was a significant predictor of follow-up
POMS anxiety, such that patients who preferred
passive involvement in treatment decision making
reported greater anxiety than patients who wanted
to be actively involved.
Psycho-Oncology 13: 235–247 (2004)
242
T.F. HACK AND L.F. DEGNER
Table 4. Multiple regression analyses of follow-up psychological adjustment (POMS) by baseline preference for decisional
control*
Dependent
variable
Depression
ns.
Confusion
ns.
Anxiety
Decisional
control preference
Anger
Decisional
control preference
Fatigue
ns.
Vigor
ns.
Friendliness
ns.
True POMS total
ns.
POMS negative
Decisional
control preference
POMS positive
ns.
DR2
Cumulative
R2
Beta
weight
p
0.081
0.242
0.306
0.031
0.075
0.133
0.290
0.047
0.065
0.228
0.270
0.050
*The following variables were forced into the analysis of each
dependent variable as the initial entry step: Age; education;
tumor stage; type of surgery; and adjuvant treatment.
DISCUSSION
Patients whose coping style at time of adjuvant
treatment planning was marked by a lack of
avoidance coping}particularly lack of cognitive
avoidance}and moderate approach coping, continued to have better psychological adjustment at
follow-up. These low cognitive avoidance/moderate approach patients had significantly lower levels
of anxiety and negative mood (as indicated by true
POMS score) at follow-up, and significantly higher
levels of friendliness and overall positive mood.
Patients whose coping style was marked by high
avoidance had significantly lower levels of vigor.
These findings suggest that the manner by which a
women with breast cancer copes with a diagnosis
of breast cancer is indicative of her mood state
three years post-diagnosis.
To shed more light on the contribution of
coping response and mood state at time of
Copyright # 2003 John Wiley & Sons, Ltd.
adjuvant treatment planning to mood state three
years later, data for all coping clusters were
combined. These two variables, together with
demographic, illness and treatment data, and
decisional role preference, accounted for between
27.8 and 44.5% of the variance in follow-up mood
state, depending on the mood state variable being
assessed. The most frequently significant predictors of negative mood state were the acceptance/
resignation subscale of the CRI and the depression
subscale of the POMS. Baseline scores on these
subscales were significant predictors of true POMS
total score, POMS negative score, and POMS
depression at follow-up. Baseline acceptance/resignation was also a significant predictor of
confusion, fatigue, vigor, friendliness, and POMS
positive score at follow-up. Likewise, POMS
depression at baseline was a significant predictor
of follow-up anxiety and anger.
Given the robust nature of the acceptance/
resignation subscale as a predictor of psychological adjustment at the three-year follow-up, the
items which comprise this subscale warrant review.
The six items include: ‘Did you feel that time
would make a difference}the only thing to do was
wait?’; ‘Did you realize that you had no control
over the problem?’; ‘Did you think that the
outcome would be decided by fate?’; ‘Did you
accept it; nothing could be done?’; ‘Did you expect
the worst possible outcome?’; and ‘Did you lose
hope that things would ever be the same?’. These
avoidance questions are characterized by a sense
of loss of control, helplessness, and hopelessness.
In this respect, these questions share features of
depression. Yet, the depression subscale was a
significant predictor of negative adjustment in
addition to the acceptance/resignation subscale.
Therefore, the current data suggest that depressive
mood, and the depressive features of loss of
control and hopelessness at time of adjuvant
treatment planning are independent predictors of
poor long-term psychological adjustment. The
mechanism by which these variables are linked
across time is not known. The fact that this
significant relationship was realized calls into
question the extent to which baseline levels of
depression and responses of resignation/acceptance are more state-like, i.e. attributable to
having received a life-threatening cancer diagnosis,
versus being more trait-like, i.e. predating the
cancer diagnosis and more generally defining
the patient’s personality, character, or coping
disposition.
Psycho-Oncology 13: 235–247 (2004)
COPING RESPONSES AND PSYCHOLOGICAL ADJUSTMENT
243
Table 5. Multiple regression analyses of follow-up psychological adjustment (POMS)}final model*
Dependent variable
Depression
Depression (POMS)
Acceptance/resignation (CRI)
Confusion
Acceptance/resignation (CRI)
Confusion (POMS)
Anxiety
Depression (POMS)
Decisional control preference
Anger
Depression (POMS)
Emotional discharge (CRI)
Fatigue
Acceptance/resignation (CRI)
Vigor
Acceptance/resignation (CRI)
Problem solving (CRI)
Friendliness
Friendliness (POMS)
Acceptance/resignation (CRI)
True POMS total
Acceptance/resignation (CRI)
Depression (POMS)
POMS negative
Depression (POMS)
Acceptance/resignation (CRI)
POMS positive
Problem solving (CRI)
Acceptance/resignation (CRI)
DR2
Cumulative R2
0.264
0.044
0.382
0.426
0.440
0.238
50.001
50.001
0.124
0.032
0.268
0.300
0.264
0.221
0.016
0.014
0.192
0.031
0.351
0.382
0.413
0.194
0.002
0.001
0.181
0.039
0.239
0.278
0.357
0.224
0.034
0.024
0.064
0.335
0.260
0.002
0.121
0.060
0.261
0.321
$0.295
0.262
0.019
0.008
0.232
0.035
0.410
0.445
0.433
$0.201
50.001
50.001
0.182
0.066
0.361
0.427
0.314
0.303
0.001
50.001
0.182
0.056
0.346
0.402
0.335
0.269
0.015
0.042
0.137
0.079
0.311
0.390
0.312
$0.297
0.014
0.018
Beta weight
p
*The following variables were forced into the analysis of each dependent variable as the initial entry step: Age; education; tumor
stage; type of surgery; and adjuvant treatment.
One way of addressing this question is to
examine the efficacy of a coping skills intervention
and/or psychotherapy regimen designed to enhance the psychological well-being of patients who
receive a diagnosis of breast cancer. The extent to
which baseline coping responses and level of
psychological adjustment are amenable to change
via intervention may indicate whether or not the
scores on these variables are reflective of stable,
underlying personality structures that predate the
cancer diagnosis, or an adjustment response to
having cancer. The latter is suggested by the results
of empirical studies of (i) supportive-expressive
therapy groups indicating that this type of group
therapy leads to improvement in confrontative
coping strategies and an improvement in wellbeing in breast cancer patients (Goodwin et al.,
2001; Spiegel et al., 1999), and (ii) coping skills and
cognitive-behavioral programs that have been
Copyright # 2003 John Wiley & Sons, Ltd.
shown to enhance emotional well-being (Edgar
et al., 2001), reduce depression (Antoni et al.,
2001), and reduce serum cortisol levels (Cruess
et al., 2000) in women with breast cancer.
The present finding of a strong association
between acceptance/resignation coping at time of
adjuvant treatment planning and poor psychological adjustment three years later supports previous studies that found a significant relationship
between poor psychological adjustment and general avoidance coping (McCaul et al., 1999;
Shapiro et al., 1997; Stanton and Snider, 1993),
fatalism (Schnoll et al., 1998) and helplessness
(Burgess et al., 1988; Schnoll et al., 1998).
Avoidance-based coping responses appear to be
associated with increased psychological distress.
The significant relationship between acceptance/
resignation and poor psychological adjustment is,
however, inconsistent with previous reports that
Psycho-Oncology 13: 235–247 (2004)
244
T.F. HACK AND L.F. DEGNER
acceptance (Carver et al., 1993) and active
acceptance at diagnosis (Stanton et al., 2002) are
significantly related to positive adjustment to
cancer. In these two latter studies, acceptance
was measured using the COPE inventory (Carver
et al., 1989). An example item from the acceptance
subscale is: ‘I accept the reality of the fact that it
happened’. This item is distinct from the items
from the CRI acceptance/resignation subscale in
that it addresses an acknowledgement and acceptance of the truth of the cancer diagnosis without
tapping into a patient’s perceptions and experiences of loss of control, hopelessness, or helplessness. These two means of measuring
acceptance may be addressing two distinct constructs that are differentially related to adjustment.
Accepting the reality of cancer may indeed be
psychologically adaptive for a patient, while a
resigned acceptance to the difficulties associated
with a cancer diagnosis may be maladaptive. It is
not so surprising then, that acceptance has been
shown to be related to both positive and negative
psychological adjustment to breast cancer.
Given that the problem-solving subscale of the
CRI was also a significant predictor of POMS
positive score and the POMS vigor subscale,
interventions designed to facilitate positive coping
responses and well-being among cancer patients
should include practical assistance to enhance
patients’ efforts to manage their emotional reactions to their diagnosis and participate knowledgeably in treatment decision making.
With respect to treatment decision making,
patient preference for involvement in treatment
decision making at baseline was a significant
predictor of anxiety three years later. Those
patients who expressed a preference for a passive
role in decision making, i.e. deferring to their
oncologists when decisions were to be made, were
more highly anxious at follow-up. Although not
significant in the final model, examination of the
decisional control variable alone showed that
patients who preferred a passive role had significantly higher anger scores on the POMS, and
significantly higher POMS negative scores, at
follow-up than patients who preferred to be
actively involved in making treatment decisions.
With respect to the expression of negative
emotions, scores on the Anger Expression Inventory did not change from baseline to follow-up
and, like the baseline findings, these scores did not
differ significantly across the three coping clusters
at baseline. Follow-up scores on the anger subscale
Copyright # 2003 John Wiley & Sons, Ltd.
of the POMS were also not significantly different
across the coping clusters. After collapsing the
data, however, to consider all the patients
together, the emotional discharge subscale of the
CRI was a significant predictor of follow-up anger,
as measured by the POMS. The POMS depression
subscale was also significantly related to follow-up
anger. The emotional discharge subscale is classified under behavioral avoidance coping. As an
avoidance subscale, one would hypothesize that
emotional discharge would be significantly related
to poor psychological adjustment, and this is
indeed indicated in the results. A recent study,
however, had demonstrated that emotional expression is significantly related to positive adjustment (Stanton et al., 2000). Closer examination of
the items that comprise the emotional discharge
subscale of the CRI suggests that this subscale is
more closely related in content to ‘emotional
upset’ than to the free expression of feeling states.
Examples of items that comprise this subscale
include ‘Did you yell or shout to let off steam?’,
‘Did you cry to let your feelings out?’, and ‘Did
you take it out on other people when you felt
angry or depressed?’. In the Stanton et al. (2000)
study, emotional expression was assessed by the
following two items: ‘I take time to express my
emotions’; and ‘I feel free to express my emotions’.
This serves to illustrate how differences in wording
across similarly themed scales can lead to disparate
findings that are only understood after evaluating
the items which comprise the scales. This difficulty
may be remedied, in part, by the development and
universal acceptance of a single scale for the
measurement of coping in psycho-oncology research. In the mean time, ease of understanding
the results of coping studies may be facilitated by
listing items of lesser known scales and questionnaires in published reports.
A limitation of the present study is the lack of
recurrence data for the women of the sample. It is
possible that follow-up psychological adjustment
is associated with advancing disease, but the
prevalence of disease recurrence in the sample
was not measured. One would expect that psychological adjustment would be negatively altered by
progressive disease. It would have been valuable to
examine the proportion of variance in psychological adjustment accounted for by recurrence status,
and to see whether the relationships between
baseline levels of adjustment and coping response
were maintained after the addition of recurrence
status to the empirical model. It may prove fruitful
Psycho-Oncology 13: 235–247 (2004)
COPING RESPONSES AND PSYCHOLOGICAL ADJUSTMENT
in future studies to assess}and target for therapeutic change}patients’ recurrence fears, given
the positive association between expectancies of
cancer recurrence and psychological distress that
has been identified (Carver et al., 2000).
The present research has established a significant relationship between the coping responses of
women with breast cancer around the time of
adjuvant treatment planning, and subsequent
psychological adjustment three years later. The
fact that cluster analytic methods can be used to
identify distinct groups of women characterized by
unique coping profiles, coupled with the finding
that these subgroups of women differ significantly
with respect to psychological adjustment some
three years later, suggests that we can identify}early in the disease process}women who
are at risk for poor psychological adjustment to
their cancer. This knowledge may be used in the
application of coping skills programs and cognitive-behavioral interventions to better assist women as they strive to manage the many and varied
challenges imposed upon them by their breast
cancer.
ACKNOWLEDGEMENTS
This research was supported by research grant #006285
from the Canadian Breast Cancer Research Initiative.
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