Chronotype Differences in Health Behaviors and Health-Related Quality of Life: A Population-Based Study Among Aged and Older Adults.

This study investigates health behaviors, health-related quality of life (HRQOL) and sleep among chronotypes in a community-based sample (n = 2,976). Analysis of covariance indicated evening types (E-types) had a significantly higher percentage of current smokers and more sleep-interfering behaviors compared to intermediate and morning types (M-type), and also lower physical activity and more sleep disturbance compared to M-types. E-types also had worse mental HRQOL compared to both chronotypes, and worse physical HRQOL compared to M-types. Exploratory analyses indicated E-types consumed more caffeinated beverages at night, smoked or ate heavy meals before bedtime, kept irregular sleep-wake schedules, and took more naps. Mediational analyses indicated that sleep-interfering behavior partially mediated the relationship between chronotype and sleep disturbance, and physical activity partially mediated the relationship between chronotype and mental HRQOL. E-types had more unhealthy behaviors, which may subsequently place them at higher risk for health problems.

Association of the physiological stress response with depressive symptoms in patients with breast cancer.

OBJECTIVE: The literature on the relationship of depressive symptoms and stress hormones after cancer diagnosis has been mixed, with some studies showing a relationship and other studies showing none. Time since diagnosis may explain these contradictory findings. This study examined the relationship of depressive symptoms to stress hormones in patients with breast cancer using 12-month longitudinal data. METHODS: Patients with Stage II or III breast cancer (n = 227) were assessed every 4 months from diagnosis/surgery to 12 months. They completed the Centers for Epidemiological Studies Depression Scale (CES-D) Iowa Short Form and the Perceived Stress Scale and blood samples were obtained to measure stress hormones (i.e., cortisol, adrenocorticotropin hormone, norepinephrine, and epinephrine). RESULTS: Depressive symptoms were negatively related to cortisol levels (ß= -0.023, p = .002) but were positively related to rate of change in cortisol (ß = 0.003, p = .003). Adrenocorticotropin hormone, epinephrine, and norepinephrine did not covary with depressive symptoms (all p values > .05). When the CES-D and Perceived Stress Scale were both used to predict cortisol, only the CES-D was significantly related (ß = -0.025, p = .017). CONCLUSIONS: Depressive symptoms were negatively related to cortisol, but this relationship changed from the time of diagnosis/surgery through 12 months. Cortisol may initially provide a buffering effect against depression during the stress of initial diagnosis and treatment, but this relationship seems to change over time.

Factor analytic and item response theory evaluation of the Penn State Worry Questionnaire in women with cancer.

PURPOSE: Cancer survivors frequently experience worry about a variety of topics, including fear of recurrence. However, general measures of worry still require examination of reliability for this vulnerable population. This study utilized modern psychometric methods to examine the reliability of a worry measure in women with breast or gynecologic cancer. METHODS: Women with cancer (n = 332) completed the 16-item Penn State Worry Questionnaire (PSWQ), which has an abbreviated 8-item version (PSWQ-A). Categorical confirmatory factor analysis (CCFA) was used to determine the factor structure and item response theory (IRT) was used to examine score reliability. RESULTS: CCFA supported a two-factor structure with 11 positively worded items and the 5 negatively worded items loading on different factors. IRT analysis of the 11 positively worded items showed that each was contributing meaningful information to the overall scores. The 11 positively worded items and the PSWQ-A produced the most reliable scores for levels of worry ranging from one θ below to two θ above the mean. CONCLUSIONS: The 11 positively worded items of the PSWQ and the 8-item PSWQ-A were suitable for use in cancer patients while the full PSWQ was unsuitable due to inclusion of the negatively worded items. Future research should consider measuring worry when examining distress in cancer survivors.

A randomized controlled trial of a behavioral intervention for decreasing bedtime procrastination using a wait-list control group in a non-clinical sample of young adults.

STUDY OBJECTIVES: Bedtime Procrastination (BP) is defined as the behavior of going to bed later than intended, without external reasons. This study is a randomized controlled trial aiming to establish efficacy of a behavioral intervention to decrease BP in a non-clinical sample. METHOD: This was an open-label trial that was conducted in sixty participants (mean age 21.33 ± 2.35 years, 86.7% females) without insomnia or psychopathology who endorsed frequent BP. They were randomized to either the treatment group (n = 32) or wait-list control group (n = 28). Participants completed the Bedtime Procrastination Scale (BPS), the Epworth Sleepiness Scale (ESS), the Insomnia Severity Index (ISI), Center for Epidemiologic Studies Depression Scale (CES-D), Morningness-Eveningness Questionnaire (MEQ), and a weekly sleep diary. Functional analysis was conducted to investigate the function of BP. Linear mixed models were used for analyses. RESULT: The treatment group showed significant improvement on the BPS (35.56% decrease, d = 2.19, bedtime procrastination duration based on the sleep diary (-46.29 min, d = 1.22), and sleep efficiency (5.70% increase, d = 1.25) compared to the wait-list control group following the intervention. There were also significant reductions in time spent from bedtime to lights out, and wake time to time out of bed, in addition to improvements in ISI and ESS scores in the treatment group compared to the control group. Functional analysis results indicated emotional regulation (31.3%), compensation (26.5%), and social interaction and belongingness (18.1%) as the most frequent functions of bedtime procrastination. CONCLUSION: This study shows promising results for a behavioral intervention targeting BP and sleep. In addition, this study demonstrated various functions of BP as a sleep-interfering behavior. We expect that these findings could be used in future studies and clinical settings to decrease BP.

Impact of breast cancer recurrence and cancer-specific stress on spouse health and immune function.

Spouses of cancer patients are at-risk for poor psychological and physical health as they cope with the complex nature of the disease and fears of losing their partner. Moreover, spouses often serve as patients' primary informal caregivers, a group that evidences poor outcomes across a variety of domains. The present study examines the relative contributions of cancer recurrence - a cancer-specific stressful event - and the subjective experience of cancer-specific stress (IES) in a sample of male spouses of breast cancer survivors. We hypothesized that stress would contribute to poorer physical health and compromised immune function. Spouses (recurrence; n=16) of patients who were coping with their first recurrence were matched to spouses of patients with no evidence of disease (disease-free; n=16). Self-reported physical health (physical symptoms and fatigue) and immune function [T-cell blastogenic response to the mitogens Concanavalin A (ConA) and phytohemagglutanin (PHA) and T3 monoclonal antibody (T3 Mab)] were included as outcomes. Results indicated that patient recurrence status was not a significant unique predictor of physical health or immune function; rather, among all spouses, cancer-specific stress symptoms were associated with increased physical symptoms and altered T-cell blastogenesis. These data suggest that the health implications of caregiving for spouses of cancer survivors is more strongly linked to their subjective experience of cancer as stressful, rather than simply the patients' disease status.

Psychological stress is associated with altered levels of myeloid-derived suppressor cells in breast cancer patients.

Our group has shown in a randomized clinical trial that psychological intervention to reduce stress in patients with stages II and III breast cancer led to enhanced immune function, fewer recurrences and improved overall survival. We hypothesized that patients with high levels of stress would have alterations in myeloid-derived suppressor cells (MDSC) compared to patients with lower stress. PBMC from 16 patients with high stress (n = 8) or with low stress (n = 8) after surgery as measured by the Impact of Event Scale (IES) questionnaire were evaluated for the presence of MDSC. Patients with higher IES scores had significantly elevated salivary cortisol levels (P = 0.013; 13 µg/dl vs. 9.74 µg/dl). Levels of IL-1Rα were also significantly elevated in the higher IES group (45.09 pg/ml vs. 97.16 pg/ml; P = 0.010). IP 10, G-CSF, and IL-6 were all higher in the high stress group although not to a significant degree. Flow cytometric analysis for CD33+/HLA-DR-neg/CD15+/CD11b+ MDSC revealed increased MDSC in patients with lower IES scores (P = 0.009). CD11b+/CD15+ cells constituted 9.4% of the CD33+/HLA DR-neg cell population in patients with high IES, vs. 27.3% in patients with low IES scores. Additional analyzes of the number of stressful events that affected the patients in addition to their cancer diagnosis revealed that this type of stress measure correlated with elevated levels of MDSC (P = 0.064). These data indicate the existence of a complex relationship between stress and immune function in breast cancer patients.

Determinants of physical activity among women treated for breast cancer in a 5-year longitudinal follow-up investigation.

OBJECTIVE: To estimate the 5-year trajectory of physical activity among women with breast cancer, and to evaluate biopsychosocial variables (health status, physical symptoms, health-related quality of life (HRQL), depressive symptoms, and social support), measured soon after breast cancer diagnosis, as predictors of the 5-year trajectory. METHODS: Women diagnosed with Stage II or III regional breast cancer (n=227), surgically treated and awaiting the start of adjuvant therapy completed baseline assessments of medical, psychological, and behavioral functioning. Follow-up evaluations were conducted every 4 months during the first year and every 6 months during the subsequent 4 years (12 assessments total during the 5-year study). Mixed-effects modeling was utilized to estimate the baseline level of physical activity as well as rate of change over time. Measures of physical health status, HRQL, depressive symptoms, and social support were included as predictors of the physical activity trajectory. RESULTS: A curvilinear pattern of change in physical activity was evident over the 5-year follow-up (p=0.002). Physical activity increased gradually during the first 18 months, then declined steadily over the subsequent 42 months. Poor physical health, depressive symptoms, and lower emotional HRQL were associated with less physical activity. Higher family support was associated with a slower decline in physical activity in the latter 42 months of the study. CONCLUSIONS: Emotional HRQL following diagnosis with breast cancer appears to be important for sustaining physical activity in the first 1-2 years following diagnosis. Physical activity interventions among breast cancer survivors should address depressive symptoms early in the course of treatment.

Stress and quality of life in breast cancer recurrence: moderation or mediation of coping?

BACKGROUND/PURPOSE: Diagnosis with breast cancer recurrence often brings high levels of stress. Successful coping to alleviate stress could improve patients' quality of life (QoL). The intervening role coping plays between stress and QoL may depend on the types of stress encountered and the types of coping strategies used. The present study investigates the longitudinal relationships between stress, coping, and mental health QoL. METHODS: Breast cancer patients recently diagnosed with recurrence (N = 65) were assessed shortly after the diagnosis and 4 months later. Four moderation and four mediation models were tested using hierarchical multiple regressions and path analyses. In the models, either traumatic stress or symptom-related stress at recurrence diagnosis was a predictor of mental health QoL at follow-up. Both engagement and disengagement coping strategies were tested as moderators or mediators between stress and QoL. RESULTS: Engagement coping moderated the effect of symptom stress on mental health QoL, whereas disengagement coping mediated the effects of both traumatic stress and symptom stress on mental health QoL. CONCLUSION: The findings imply that interventions teaching engagement coping strategies would be important for patients experiencing high symptom stress, while discouraging the use of disengagement coping strategies would be important for all patients.

Longitudinal Lung Function Decrease in Subjects with Spontaneous Healed Pulmonary Tuberculosis.

OBJECTIVE: We compared the longitudinal course of post-bronchodilator Forced Expiratory Volume in 1 second (pFEV1) over a 10-year period in subjects with spontaneous healed pulmonary tuberculosis (SHPTB) with that in normal subjects. METHODS: We prospectively investigated 339 subjects with SHPTB and 3211 normal subjects. pFEV1 values measured biannually over 10 years were analyzed using mixed effects model. RESULTS: At baseline, there were no differences in gender, smoking amount, and mean height, except mean age (50.0 ± 8.1 VS. 48.1 ± 7.3, P< 0.001) between the SHPTB and normal group. 52% of the 339 participants with SHPTB and 56% of the 3211 normal participants participated till the end of study. According to the final model, the SHPTB group showed significantly larger decrease in the average pFEV1 over the time than the normal group (P< 0.001) adjusted for gender, age, height, smoking pack years, and time effects. Especially, the interaction effect between time and group was statistically significant (P = 0.036). CONCLUSION: The average lung function in terms of pFEV1 decreases faster in subjects with SHPTB than in normal individuals over time.

Who is at risk for having persistent insomnia symptoms? A longitudinal study in the general population in Korea.

OBJECTIVES: Our study had three goals: (1) to investigate the longitudinal course of insomnia symptoms over 4 years (3 time points) by analyzing the trajectory of insomnia symptoms for all participants, (2) to compare persistent insomnia symptom to nonpersistent insomnia symptom groups on mental health and quality of life (QoL), and (3) to conduct exploratory analyses on the relative contribution of multiple factors to persistence of insomnia symptoms. METHODS: Our population-based longitudinal study utilized a community-based sample from the Korean Genome and Epidemiology study (KoGES). Participants were 1247 individuals (40.1% men; mean age, 54.3±7.1 years). Insomnia, QoL (measured by 12-item Short-Form health survey [SF-12]), sleep-interfering behaviors, and depression (measured by the Beck Depression Inventory [BDI]) were followed with biennial examinations at 3 data points spaced 2 years apart (baseline, time 1, and time 2). RESULTS: Among individuals experiencing insomnia symptoms at baseline, the most common trajectory was to experience persistent nocturnal insomnia symptoms across all 3 time points. Those with persistent insomnia symptoms had significantly lower physical and mental QoL (measured by SF-12) and higher depression (measured by BDI) at time points compared to those without persistent nocturnal insomnia symptoms. A follow-up exploratory receiver operating characteristic curve (ROC) analysis identified poor sleep quality, frequent sleep-interfering behaviors, and low mental health QoL as the strongest predictors of persistent insomnia symptoms above other well-known risk factors. CONCLUSIONS: In particular, an interaction between poor sleep quality, sleep-interfering behaviors, and mental health QoL appeared to be the strongest risk factor for persistent insomnia symptoms.

Longitudinal course of depression scores with and without insomnia in non-depressed individuals: a 6-year follow-up longitudinal study in a Korean cohort.

STUDY OBJECTIVE: This is a population-based longitudinal study that followed insomnia symptoms over a 6-year period in non-depressed individuals. The purpose of the study was to (1) investigate the longitudinal course of depression based on number of insomnia episodes; and (2) describe longitudinal associations between insomnia and depression, and insomnia and suicidal ideation. DESIGN: Population-based longitudinal study. SETTING: Community-based sample from the Korean Genome and Epidemiology Study (KoGES). PARTICIPANTS: 1,282 non-depressed individuals (44% male, mean age 52.3 ± 7.14 years). MEASUREMENTS AND RESULTS: This study prospectively assessed insomnia, depression, and suicidal ideation with 4 time points. Individuals were classified into no insomnia (NI), single episode insomnia (SEI), and persistent insomnia (PI; ≥ insomnia at 2+ time points) groups based on number of times insomnia was indicated. Mixed effects modeling indicated that depression scores increased significantly faster in the PI group compared to the NI (P < 0.001) and SEI (P = 0.02) groups. Additionally, the PI group had significantly increased odds of depression as compared to NI or SEI (OR 2.44, P = 0.001) groups, with 18.7% meeting criteria for depression compared to the NI (5.3%) and SEI (11.6%) groups at end point. The PI group also had significantly increased odds of suicidal ideation as compared to NI or SEI (OR 1.86, P = 0.002) groups. CONCLUSIONS: Persistent insomnia significantly increases the rate in which depression occurs over time in non-depressed individuals, which ultimately leads to higher risk for depression. Additionally, having persistent insomnia also increased the risk of suicidal ideation. CITATION: Suh S; Kim H; Yang HC; Cho ER; Lee SK; Shin C. Longitudinal course of depression scores with and without insomnia in non-depressed individuals: a 6-year follow-up longitudinal study in a Korean cohort. SLEEP 2013;36(3):369-376.

Testing bidirectional relationships between marital quality and sleep disturbances: a 4-year follow-up study in a Korean cohort.

OBJECTIVE: Both poor marital quality and sleep disturbances are risk factors for a broad range of mental and physical health morbidities. The purpose of the study was to investigate bidirectional relationships between marital quality and sleep disturbance and the moderating effects of age and gender. METHODS: Data from 1081 married individuals who participated in the Korean Genome and Epidemiology Study were analyzed. A marital quality questionnaire and the Pittsburgh Sleep Quality Index were used to assess marital quality and sleep disturbances at baseline and 4-year follow-up. Relevant covariates including sociodemographics, health status, health behaviors, and depressive symptoms were also measured. RESULTS: Hierarchical multiple regression models revealed that there was a significant interaction between marital quality and age predicting sleep disturbance (P=.017). While there was no association between marital quality and sleep disturbances for the younger group (ages 45-54; n=680), persons with lower marital quality were more likely to have greater sleep disturbances 4 years later for the older group (ages 55-74; n=401). By contrast, sleep disturbance was a significant predictor of marital quality 4 years later, regardless of age or gender (P=.025). CONCLUSION: Poor marital quality is a risk factor for sleep disturbance for older adults but not for middle-aged individuals. In turn, sleep disturbance may lead to lower marital quality for all age groups. Clinicians should be aware of the bidirectional relationships between marital and sleep problems for more effective treatments for both.

Longitudinal course of insomnia: age-related differences in subjective sleepiness and vigilance performance in a population-based sample.

OBJECTIVE: The present study utilized a population-based sample investigating the following aims: (1) compare the longitudinal course of insomnia in middle-aged and older adults and (2) examine age-related differences on subjective complaint and objective performance in middle-aged and older adults based on the course of insomnia. METHODS: 1657 middle-aged adults (48.16% male, mean age=55.35±4.03years) and 405 older adults (48.40% male, mean age=70.13±3.88years) from the Korean Genome and Epidemiology Study (KoGES) were classified into 4 groups - no insomnia (NI), single episode insomnia (SEI), remitted persistent insomnia (PI-R), and ongoing persistent insomnia (PI-O) based on their course of insomnia over 5 time points spaced two years apart. Their performance on the psychomotor vigilance task (PVT) and subjective daytime sleepiness were compared across different insomnia groups, and the results were compared between middle-aged adults and older adults. RESULTS: Analysis of covariance indicated that subjective daytime sleepiness was significantly different across the insomnia groups in middle-aged adults based on insomnia group (P=<.0001), but, did not affect objective vigilance performance. In contrast, older adults displayed significantly different PVT response time, but not daytime sleepiness, based on insomnia group (P=0.03). CONCLUSION: Insomnia impacts psychomotor performance and subjective sleepiness differently, based on age group. There may be underlying processes associated with the aging that amplifies the impact of insomnia on vigilance performance, yet lessens perceived sleepiness in older adults.

The effect of anxiety on heart rate variability, depression, and sleep in chronic obstructive pulmonary disease.

OBJECTIVES: The current study investigates heart rate variability (HRV) responses to a psychosocial stressor in chronic obstructive pulmonary disease (COPD) patients, and the potential role of anxiety as a confounding factor in this relationship. Additionally, this study also investigates the influence of anxiety on sleep and depressive symptoms among COPD patients. METHODS: The study utilized a 2 (disease status)×2 (anxiety group) factorial design examining HRV associated with anxiety symptoms and COPD during a standardized acute social stress task. Participants (mean age 59.1±11.2 years; 50% female) completed pulmonary function testing, HRV monitoring, and self-report questionnaires assessing psychological factors. 30 COPD patients were age- and gender-matched with 30 healthy controls. RESULTS: HRV response to a psychosocial stressor among participants with higher anxiety (both COPD and healthy) reflected autonomic dysregulation in both time and frequency domains that was not evident among non-anxious participants. COPD participants with higher anxiety reported greater symptoms of depression and poorer sleep quality than did COPD participants with low anxiety. CONCLUSIONS: Anxiety is associated with dysregulated HRV response to a psychosocial stressor, but the negative influence of anxiety and COPD on autonomic function did not appear to be additive. Comorbid anxiety in patients with COPD is associated with increased behavioral and psychological symptoms of distress.

Cancer patients with major depressive disorder: testing a biobehavioral/cognitive behavior intervention.

OBJECTIVE: In this Phase II trial, we evaluated a novel psychological treatment for depressed patients coping with the stresses of cancer. Effectiveness of a combined biobehavioral intervention (BBI) and cognitive behavior therapy (CBT) was studied. METHOD: Participants were 36 cancer survivors (mean age = 49 years; 88% Caucasian; 92% female) diagnosed with major depressive disorder. A single group pre-post design was used. Treatment consisted of up to 20 individual 75-min combined BBI/CBT sessions. Outcomes were change in interviewer (Hamilton Rating Scale for Depression; Williams, 1988) and self-rated depressive symptoms (Beck Depression Inventory-Second Edition; Beck, Steer, & Brown, 1996) as well as change in cancer relevant symptoms (Fatigue Symptom Inventory [Hann et al., 1998] and Brief Pain Questionnaire [Daut, Cleeland, & Flanery, 1983]) and quality of life (Medical Outcomes Study Short Form-36; Ware et al., 1995). Mixed-effects modeling, a reliability change index, and generalized linear models were used. All analyses were intent-to-treat. RESULTS: Depressive symptoms significantly improved. In addition, 19 of 21 study completers met criteria for remission. Significant improvements were also noted in fatigue and mental health quality of life. Both concurrent anxiety disorders and high levels of cancer stress (Impact of Events Scale; Horowitz, Wilner, & Alvarez, 1979) were each associated with beginning and concluding treatment with greater depressive symptoms. CONCLUSIONS: CBT components were successfully incorporated into a previously efficacious intervention for reducing cancer stress. The BBI/CBT intervention warrants further research in evaluating its efficacy compared with well-established treatments for depression.

Biobehavioral, immune, and health benefits following recurrence for psychological intervention participants.

PURPOSE: A clinical trial was designed to test the hypothesis that a psychological intervention could reduce the risk of cancer recurrence. Newly diagnosed regional breast cancer patients (n = 227) were randomized to the intervention-with-assessment or the assessment-only arm. The intervention had positive psychological, social, immune, and health benefits, and after a median of 11 years the intervention arm was found to have reduced the risk of recurrence (hazard ratio, 0.55; P = 0.034). In follow-up, we hypothesized that the intervention arm might also show longer survival after recurrence. If observed, we then would examine potential biobehavioral mechanisms. EXPERIMENTAL DESIGN: All patients were followed; 62 recurred. Survival analyses included all 62. Upon recurrence diagnosis, those available for further biobehavioral study were accrued (n = 41, 23 intervention and 18 assessment). For those 41, psychological, social, adherence, health, and immune (natural killer cell cytotoxicity, T-cell proliferation) data were collected at recurrence diagnosis and 4, 8, and 12 months later. RESULTS: Intent-to-treat analysis revealed reduced risk of death following recurrence for the intervention arm (hazard ratio, 0.41; P = 0.014). Mixed-effects follow-up analyses with biobehavioral data showed that all patients responded with significant psychological distress at recurrence diagnosis, but thereafter only the intervention arm improved (P values < 0.023). Immune indices were significantly higher for the intervention arm at 12 months (P values < 0.017). CONCLUSIONS: Hazards analyses augment previous findings in showing improved survival for the intervention arm after recurrence. Follow-up analyses showing biobehavioral advantages for the intervention arm contribute to our understanding of how improved survival was achieved.

Marital quality and survivorship: slowed recovery for breast cancer patients in distressed relationships.

BACKGROUND: Although marital distress has been implicated in difficulties with adjustment to a breast cancer diagnosis, its long-term effects, especially on physical recovery, are unknown. METHODS: Longitudinal data from newly diagnosed breast cancer patients (N=100) who were married or cohabiting were used. Patients were assessed after diagnosis and surgery (baseline) and then reassessed every 4 or 6 months for the next 5 years. Women in stable, distressed relationships (n=28) were compared with those in stable, nondistressed relationships (n=72). Stress, health behavior, and health outcomes were examined using mixed-effects modeling. RESULTS: Overall, marital distress was associated with slowed recovery trajectories and poor outcomes. At baseline, both groups had equivalent, high levels of stress, but diverged thereafter. Stress declined more slowly for the Distressed group, and by 5 years it remained significantly higher. Differential reductions in physical activity were also observed. With regard to health, the Distressed group was found to have a slower recovery in performance status and more symptoms/signs of illness and treatment side effects through 3 years. Finally, all the effects were observed above and beyond reductions occurring with depressive symptomatology, which was significantly higher in the Distressed group. CONCLUSIONS: Marital distress is not only associated with worse psychologic outcomes for breast cancer survivors, but poorer health and a steeper decline in physical activity. These novel data demonstrate recovery trajectories for breast cancer survivors to be constrained for those also coping with ongoing difficulties in their marriage.

Surviving recurrence: psychological and quality-of-life recovery.

BACKGROUND: To the authors' knowledge, data characterizing patients' psychosocial experiences after a recurrence diagnosis are limited. This report provides the physical, psychological, and quality-of-life trajectories of patients with recurrent breast cancer. In addition, patients with a well-documented trajectory -- patients with their initial diagnosis of breast cancer -- were included as a referent group, providing a metric against which to gauge the impact and course of cancer recurrence. METHODS: Patients with a newly diagnosed, recurrent (n = 69) or initial (n = 113) breast cancer were accrued. The groups did not differ with regard to age, race, education, family income, or partner status (all P values > .18). All patients were assessed shortly after diagnosis (baseline) and 4 months, 8 months, and 12 months later. Mixed-effects models were used to determine health status, stress, mood, and quality-of-life trajectories. RESULTS: In the year after a recurrence diagnosis, patients' physical health and functioning showed no improvement, whereas quality of life and mood generally improved, and stress declined. Compared with patients who were coping with their first diagnosis, patients with recurrence had significantly lower anxiety and confusion. In contrast, physical functioning was poorer among recurrence patients, quality-of-life improvement was slower, and cancer-related distress was high as that of the initially diagnosed patient. Slower quality-of-life recovery was most apparent among younger patients (aged <54 years). CONCLUSIONS: Despite the physical burden, patients with recurrent breast cancer exhibit considerable resilience, with steady improvements in psychological adjustment and quality of life during the year after diagnosis. Management of patients' physical symptoms is particularly important, because patients cope with recurrent breast cancer as a chronic illness.

Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial.

BACKGROUND: The question of whether stress poses a risk for cancer progression has been difficult to answer. A randomized clinical trial tested the hypothesis that cancer patients coping with their recent diagnosis but receiving a psychologic intervention would have improved survival compared with patients who were only assessed. METHODS: A total of 227 patients who were surgically treated for regional breast cancer participated. Before beginning adjuvant cancer therapies, patients were assessed with psychologic and behavioral measures and had a health evaluation, and a 60-mL blood sample was drawn. Patients were randomized to Psychologic Intervention plus assessment or Assessment only study arms. The intervention was psychologist led; conducted in small groups; and included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care. Earlier articles demonstrated that, compared with the Assessment arm, the Intervention arm improved across all of the latter secondary outcomes. Immunity was also enhanced. RESULTS: After a median of 11 years of follow-up, disease recurrence was reported to occur in 62 of 212 (29%) women and death was reported for 54 of 227 (24%) women. Using Cox proportional hazards analysis, multivariate comparison of survival was conducted. As predicted, patients in the Intervention arm were found to have a reduced risk of breast cancer recurrence (hazards ratio [HR] of 0.55; P = .034) and death from breast cancer (HR of 0.44; P = .016) compared with patients in the Assessment only arm. Follow-up analyses also demonstrated that Intervention patients had a reduced risk of death from all causes (HR of 0.51; P = .028). CONCLUSIONS: Psychologic interventions as delivered and studied here can improve survival.