Cancer-Specific Stress and Mood Disturbance: Implications for Symptom Perception, Quality of Life, and Immune Response in Women Shortly after Diagnosis of Breast Cancer
Purpose. To determine the levels of cancer-specific stress and mood disturbance in women shortly after diagnosis of breast cancer and to assess their associations with symptom perception, quality of life, and immune response. Design. Descriptive and correlational. Sample and Setting. One hundred women with newly diagnosed breast cancer were recruited from interdisciplinary breast clinics. Methods. Baseline data were collected using standardized questionnaires and established bioassay prior to the initiation of cancer adjuvant therapy. Blood samples were collected about the same time of day. Results. High cancer-specific stress was significantly correlated with high mood disturbance, which, in turn, was correlated with high symptom perception, poor quality of life, and an immune profile indicating high neutrophils and low lymphocytes. Conclusions. High cancer-specific stress and related mood disturbance show extensive negative relationships with multiple behavioral, clinical, and biological factors. Implications for Nursing. Routine screening for cancer-related stress and mood disturbance should be incorporated into nursing practice for all patients diagnosed with cancer. Given broad negative associations with other biobehavioral factors, early identification of patients at risk and provision and evaluation of stress and mood management programs may have a beneficial effect on subsequent health outcomes over time. 1. Introduction Cancer diagnosis is a significant source of psychological stress/distress (hereinafter referred to as stress), followed by an extended period of stressful cancer treatment [1–3]. Not surprisingly, patients with a diagnosis of cancer report high psychological and emotional stress [4]. Although initial stress tends to decline over time for most patients, many others continue to suffer from high stress for years even after the successful completion of cancer treatment [1]. Studies indicate that up to 30% of patients report high stress levels years from breast cancer diagnosis and surgery [1, 5]. Some patients even experience posttraumatic stress disorder precipitated by cancer diagnosis [6, 7]. Mood disturbance, particularly of depression and anxiety, is common with cancer diagnosis and has been highly correlated with psychological stress [8, 9]. About 20–40% of cancer patients have reported significant levels of depressive mood and anxiety, and these patients typically have reported higher frequency and severity of clinical symptoms, including pain, fatigue, poor appetite, sleep disturbance, and poor quality of life [10–15]. In
References
[1]
E. M. A. Bleiker, F. Pouwer, H. M. Van Der Ploeg, J. W. H. Leer, and H. J. Adèr, “Psychological distress two years after diagnosis of breast cancer: frequency and prediction,” Patient Education and Counseling, vol. 40, no. 3, pp. 209–217, 2000.
[2]
J. E. Epping-Jordan, B. E. Compas, D. M. Osowiecki et al., “Psychological adjustment in breast cancer: processes of emotional distress,” Health Psychology, vol. 18, no. 4, pp. 315–326, 1999.
[3]
H. C. Yang, B. M. Brothers, and B. L. Andersen, “Stress and quality of life in breast cancer recurrence: moderation or mediation of coping?” Annals of Behavioral Medicine, vol. 35, no. 2, pp. 188–197, 2008.
[4]
P. Hopwood, A. Howell, and P. Maguire, “Psychiatric morbidity in patients with advanced cancer of the breast: prevalence measured by two self-rating questionnaires,” British Journal of Cancer, vol. 64, no. 2, pp. 349–352, 1991.
[5]
P. A. Ganz, J. J. Lee, M. S. Sim, M. L. Polinsky, and C. A. Coscarelli Schag, “Exploring the influence of multiple variables on the relationship of age to quality of life in women with breast cancer,” Journal of Clinical Epidemiology, vol. 45, no. 5, pp. 473–485, 1992.
[6]
M. Amir and A. Ramati, “Post-traumatic symptoms, emotional distress and quality of life in long-term survivors of breast cancer: a preliminary research,” Journal of Anxiety Disorders, vol. 16, no. 2, pp. 191–206, 2002.
[7]
M. Kangas, J. L. Henry, and R. A. Bryant, “Posttraumatic stress disorder following cancer: a conceptual and empirical review,” Clinical Psychology Review, vol. 22, no. 4, pp. 499–524, 2002.
[8]
C. Hammen, “Stress and depression,” Annual Review of Clinical Psychology, vol. 1, pp. 293–319, 2005.
[9]
R. T. Liu and L. B. Alloy, “Stress generation in depression: a systematic review of the empirical literature and recommendations for future study,” Clinical Psychology Review, vol. 30, no. 5, pp. 582–593, 2010.
[10]
T. A. Badger, C. J. Braden, M. H. Mishel, and A. Longman, “Depression burden, psychological adjustment, and quality of life in women with breast cancer: patterns over time,” Research in Nursing and Health, vol. 27, no. 1, pp. 19–28, 2004.
[11]
M. Delgado-Guay, H. A. Parsons, Z. Li, J. L. Palmer, and E. Bruera, “Symptom distress in advanced cancer patients with anxiety and depression in the palliative care setting,” Supportive Care in Cancer, vol. 17, no. 5, pp. 573–579, 2009.
[12]
K. Hjerl, E. W. Andersen, N. Keiding, H. T. Mouridsen, P. B. Mortensen, and T. J？rgensen, “Depression as a prognostic factor for breast cancer mortality,” Psychosomatics, vol. 44, no. 1, pp. 24–30, 2003.
[13]
M. J. Massie, “Prevalence of depression in patients with cancer,” Journal of the National Cancer Institute, no. 32, pp. 57–71, 2004.
[14]
K. Reuter and M. H？rter, “The concepts of fatigue and depression in cancer,” European Journal of Cancer Care, vol. 13, no. 2, pp. 127–134, 2004.
[15]
J. A. Roscoe, G. R. Morrow, J. T. Hickok et al., “Temporal interrelationships among fatigue, circadian rhythm and depression in breast cancer patients undergoing chemotherapy treatment,” Supportive Care in Cancer, vol. 10, no. 4, pp. 329–336, 2002.
[16]
M. Groenvold, M. A. Petersen, E. Idler, J. B. Bjorner, P. M. Fayers, and H. T. Mouridsen, “Psychological distress and fatigue predicted recurrence and survival in primary breast cancer patients,” Breast Cancer Research and Treatment, vol. 105, no. 2, pp. 209–219, 2007.
[17]
P. L. Jenkins, V. E. May, and L. E. Hughes, “Psychological morbidity associated with local recurrence of breast cancer,” International Journal of Psychiatry in Medicine, vol. 21, no. 2, pp. 149–155, 1991.
[18]
F. R. Loberiza Jr., J. D. Rizzo, C. N. Bredeson et al., “Association of depressive syndrome and early deaths among patients after stem-cell transplantation for malignant diseases,” Journal of Clinical Oncology, vol. 20, no. 8, pp. 2118–2126, 2002.
[19]
M. Stommel, B. A. Given, and C. W. Given, “Depression and functional status as predictors of death among cancer patients,” Cancer, vol. 94, no. 10, pp. 2719–2727, 2002.
[20]
S. Cohen, “Psychological stress and susceptibility to upper respiratory infections,” American Journal of Respiratory and Critical Care Medicine, vol. 152, no. 4, part 2, pp. S53–S58, 1995.
[21]
J. K. Kiecolt-Glaser, L. McGuire, T. F. Robles, and R. Glaser, “Psychoneuroimmunology and psychosomatic medicine: back to the future,” Psychosomatic Medicine, vol. 64, no. 1, pp. 15–28, 2002.
[22]
J. K. Kiecolt-Glaser, L. McGuire, T. F. Robles, and R. Glaser, “Psychoneuroimmunology: psychological influences on immune function and health,” Journal of Consulting and Clinical Psychology, vol. 70, no. 3, pp. 537–547, 2002.
[23]
D. M. Golden-Kreutz, L. M. Thornton, S. Wells-Di Gregorio et al., “Traumatic stress, perceived global stress, and life events: prospectively predicting quality of life in breast cancer patients,” Health Psychology, vol. 24, no. 3, pp. 288–296, 2005.
[24]
K. H？rtl, J. Engel, P. Herschbach, H. Reinecker, H. Sommer, and K. Friese, “Personality traits and psychosocial stress: quality of life over 2 years following breast cancer diagnosis and psychological impact factors,” Psycho-Oncology, vol. 19, no. 2, pp. 160–169, 2010.
[25]
L. J. Luecken and B. E. Compas, “Stress, coping, and immune function in breast cancer,” Annals of Behavioral Medicine, vol. 24, no. 4, pp. 336–344, 2002.
[26]
O. Palesh, L. D. Butler, C. Koopman, J. Giese-Davis, R. Carlson, and D. Spiegel, “Stress history and breast cancer recurrence,” Journal of Psychosomatic Research, vol. 63, no. 3, pp. 233–239, 2007.
[27]
L. R. Kerr, R. Hundal, W. A. Silva, J. T. Emerman, and J. Weinberg, “Effects of social housing condition on chemotherapeutic efficacy in a shionogi carcinoma (SC115) mouse tumor model: Influences of temporal factors, tumor size, and tumor growth rate,” Psychosomatic Medicine, vol. 63, no. 6, pp. 973–984, 2001.
[28]
F. Su, N. Ouyang, P. Zhu et al., “Psychological stress induces chemoresistance in breast cancer by upregulating mdr1,” Biochemical and Biophysical Research Communications, vol. 329, no. 3, pp. 888–897, 2005.
[29]
R. Glaser, “Stress-associated immune dysregulation and its importance for human health: a personal history of psychoneuroimmunology,” Brain, Behavior, and Immunity, vol. 19, no. 1, pp. 3–11, 2005.
[30]
E. M. V. Reiche, S. O. V. Nunes, and H. K. Morimoto, “Stress, depression, the immune system, and cancer,” Lancet Oncology, vol. 5, no. 10, pp. 617–625, 2004.
[31]
S. C. Segerstrom and G. E. Miller, “Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry,” Psychological Bulletin, vol. 130, no. 4, pp. 601–630, 2004.
[32]
D. Von Ah, D. H. Kang, and J. S. Carpenter, “Stress, optimism, and social support: impact on immune responses in breast cancer,” Research in Nursing and Health, vol. 30, no. 1, pp. 72–83, 2007.
[33]
L. M. Thornton, B. L. Andersen, T. R. Crespin, and W. E. Carson, “Individual trajectories in stress covary with immunity during recovery from cancer diagnosis and treatments,” Brain, Behavior, and Immunity, vol. 21, no. 2, pp. 185–194, 2007.
[34]
J. A. Smith, “Neutrophils, host defense, and inflammation: a double-edged sword,” Journal of Leukocyte Biology, vol. 56, no. 6, pp. 672–686, 1994.
[35]
D. H. Kang, C. Christopher L, and D. O. McCarthy, “Academic examinations significantly impact immune responses, but not lung function, in healthy and well-managed asthmatic adolescents,” Brain, Behavior, and Immunity, vol. 10, no. 2, pp. 164–181, 1996.
[36]
D. H. Kang, C. L. Coe, D. O. McCarthy, and W. B. Ershler, “Immune responses to final exams in healthy and asthmatic adolescents,” Nursing Research, vol. 46, no. 1, pp. 12–19, 1997.
[37]
F. S. Dhabhar, “Stress-induced augmentation of immune function—the role of stress hormones, leukocyte trafficking, and cytokines,” Brain, Behavior, and Immunity, vol. 16, no. 6, pp. 785–798, 2002.
[38]
R. J. Benschop, M. Rodriguez-Feuerhahn, and M. Schedlowski, “Catecholamine-induced leukocytosis: early observations, current research, and future directions,” Brain, Behavior, and Immunity, vol. 10, no. 2, pp. 77–91, 1996.
[39]
F. S. Dhabhar, A. H. Miller, B. S. McEwen, and R. L. Spencer, “Stress-induced changes in blood leukocyte distribution. Role of adrenal steroid hormones,” Journal of Immunology, vol. 157, no. 4, pp. 1638–1644, 1996.
[40]
K. J. Halazun, A. Aldoori, H. Z. Malik et al., “Elevated preoperative neutrophil to lymphocyte ratio predicts survival following hepatic resection for colorectal liver metastases,” European Journal of Surgical Oncology, vol. 34, no. 1, pp. 55–60, 2008.
[41]
S. R. Walsh, E. J. Cook, F. Goulder, T. A. Justin, and N. J. Keeling, “Neutrophil-lymphocyte ratio as a prognostic factor in colorectal cancer,” Journal of Surgical Oncology, vol. 91, no. 3, pp. 181–184, 2005.
[42]
S. C. Kao, S. Klebe, D. W. Henderson, et al., “Low calretinin expression and high neutrophil-to-lymphocyte ratio are poor prognostic factors in patients with malignant mesothelioma undergoing extrapleural pneumonectomy,” Journal of Thoracic Oncology, vol. 6, no. 11, pp. 1923–1929, 2011.
[43]
M. J. Proctor, D. C. McMillan, D. S. Morrison, et al., “A derived neutrophil to lymphocyte ratio predicts survival in patients with cancer,” British Journal of Cancer, vol. 107, no. 4, pp. 695–699, 2012.
[44]
C. Peters, H. Lotzerich, B. Niemeier, K. Schule, and G. Uhlenbruck, “Influence of a moderate exercise training on natural killer cytotoxicity and personality traits in cancer patients,” Anticancer Research, vol. 14, no. 3A, pp. 1033–1036, 1994.
[45]
P. J. Diggle, K. Y. Liang, and S. L. Zeger, Analysis of Longitudinal Data, Oxford University Press, New York, NY, USA, 1994.
[46]
M. Horowitz, N. Wilner, and W. Alvarez, “Impact of event scale: a measure of subjective stress,” Psychosomatic Medicine, vol. 41, no. 3, pp. 209–218, 1979.
[47]
D. M. MacNair, M. Lorr, and L. F. Droppleman, Profile of Mood States, Educational and Testing Service, San Diego, Calif, USA, 1992.
[48]
S. Shacham, “A shortened version of the profile of mood states,” Journal of Personality Assessment, vol. 47, no. 3, pp. 305–306, 1983.
[49]
R. K. Portenoy, H. T. Thaler, A. B. Kornblith et al., “The memorial symptom assessment scale: an instrument for the evaluation of symptom prevalence, characteristics and distress,” European Journal of Cancer A, vol. 30, no. 9, pp. 1326–1336, 1994.
[50]
D. F. Cella, D. S. Tulsky, G. Gray et al., “The functional assessment of cancer therapy scale: development and validation of the general measure,” Journal of Clinical Oncology, vol. 11, no. 3, pp. 570–579, 1993.
[51]
L. E. Carlson, M. Angen, J. Cullum et al., “High levels of untreated distress and fatigue in cancer patients,” British Journal of Cancer, vol. 90, no. 12, pp. 2297–2304, 2004.
[52]
S. C. Higgins, G. H. Montgomery, G. Raptis, and D. H. Bovbjerg, “Effect of pretreatment distress on daily fatigue after chemotherapy for breast cancer,” Journal of Oncology Practice, vol. 4, no. 2, pp. 59–63, 2008.
[53]
S. Cohen, et al., “Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk,” Proceedings of the National Academy of Sciences of the United States of America, vol. 109, no. 16, pp. 5995–5999, 2012.
[54]
L. Witek-Janusek, K. Albuquerque, K. R. Chroniak, C. Chroniak, R. Durazo-Arvizu, and H. L. Mathews, “Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer,” Brain, Behavior, and Immunity, vol. 22, no. 6, pp. 969–981, 2008.
[55]
L. E. Carlson, M. Speca, K. D. Patel, and E. Goodey, “Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients,” Psychosomatic Medicine, vol. 65, no. 4, pp. 571–581, 2003.
[56]
A. Lemieux, C. L. Coe, and M. Carnes, “Symptom severity predicts degree of T cell activation in adult women following childhood maltreatment,” Brain, Behavior, and Immunity, vol. 22, no. 6, pp. 994–1003, 2008.
[57]
D. H. Kang and C. Fox, “Neuroendocrine and leukocyte responses and pulmonary function to acute stressors,” Annals of Behavioral Medicine, vol. 22, no. 4, pp. 276–285, 2000.
