Therapist and patient perceptions of alliance and progress in psychological therapy for women diagnosed with gynecological cancers.

OBJECTIVE: The goal was to understand both therapist and patient perspectives on alliance and session progress for women in treatment for gynecological cancer. We used a longitudinal version of the one-with-many design to partition variation in alliance and progress ratings into therapist, patient/dyad, and time-specific components. We also evaluated therapist and patient characteristics that predict alliance and session progress. METHOD: Two hundred and three women and their therapists completed measures of alliance and session progress across a 6-session course of treatment. Participants also completed preintervention measures of self-esteem, depression, cancer-specific distress, emotional expressivity, and use of protective buffering. RESULTS: Patients reported higher alliance and greater progress than did therapists. When therapists reported particularly strong alliance with particular patients, those patients concurred. More experienced therapists reported higher alliances and more progress but their patients did not agree. Patients who began treatment in more difficult psychosocial circumstances tended to have less positive session outcomes on average but evidenced more improvement across therapy sessions. CONCLUSIONS: Patients rated their alliance and progress more positively than did their therapists, although there was substantial relative agreement between therapists and patients. Alliance and progress improved over time, particularly among patients who evidenced higher levels of distress and poorer physical functioning. More experienced therapists were more confident in their abilities but their patients did not share this perception.

Therapy processes and outcomes of psychological interventions for women diagnosed with gynecological cancers: A test of the generic process model of psychotherapy.

OBJECTIVE: Little attention has been paid to the role of nonspecific therapy processes in the efficacy of psychological interventions for individuals diagnosed with cancer. The goal of the current study was to examine the three constructs from the generic model of psychotherapy (GMP): therapeutic alliance, therapeutic realizations, and therapeutic openness/involvement in the treatment outcome of women with gynecological cancers attending either a 7-session supportive counseling intervention or a coping and communication skills intervention. METHOD: Two hundred and three women completed measures of alliance, realizations, and openness after Intervention Sessions 2, 3, and 6, as well as measures of depressive symptoms after these sessions and 6 months after the pre-intervention assessment (posttreatment). RESULTS: Consistent with the GMP, in early sessions, therapeutic bond predicted openness in terms of positive affect experienced during sessions, and both aspects of openness (positive and negative affect), in turn, predicted more therapeutic realizations. Therapeutic realizations predicted perceptions of greater session progress, and greater therapeutic bond predicted more therapeutic realizations. When early session GMP variables were used to predict later GMP processes and outcomes and posttreatment outcomes, early therapeutic bond predicted later session therapeutic realizations directly and indirectly via emotional arousal, emotional arousal predicted session progress, session progress predicted lower postsession depressive symptoms, and depressive symptoms as rated after Session 6 predicted depressive symptoms 3 months posttreatment. However, a number of additional associations among GMP processes were found. CONCLUSIONS: Our results suggest that therapy processes played a role in predicting both short- and long-term treatment outcomes.

Mediators of a coping and communication-enhancing intervention and a supportive counseling intervention among women diagnosed with gynecological cancers.

The authors evaluated mechanisms of change for a coping and communication-enhancing intervention (CCI) and supportive counseling (SC). They proposed that the effects of CCI on depressive symptoms would be mediated by psychological processes targeted by CCI, namely increases in the following: positive reappraisal, acceptance, planful problem solving, attempts to understand emotional reactions to cancer, emotional expression, seeking of emotional and instrumental support, and self-esteem. The authors hypothesized that the effects of SC on depressive symptoms would be mediated by the processes encouraged by SC, in this case increases in the following: expression of emotions, attempts to understand emotional reactions to cancer, and self-esteem. Three hundred fifty-three women were randomized to a CCI, SC, or usual care control group and completed measures at preintervention and 3, 6, and 9 months later. The effects of CCI were fully mediated by positive reappraisal, problem solving, and self-esteem and partially mediated by emotional expression. The effects of SC were partially mediated by positive reappraisal. These findings provide support for hypothesized mediators for CCI. The authors were less able to identify mediators for SC. Future research might benefit from identifying SC mediators.

Long-term trajectories of psychological adaptation among women diagnosed with gynecological cancers.

OBJECTIVE: Women diagnosed with gynecological cancers may cope with a difficult treatment regimen that includes multiple abdominal surgeries and courses of chemotherapy and/or radiation. Little attention has been paid to identifying what factors place women at risk for long-term problems with psychological adaptation. The goal of the present study was to identify a set of demographic, medical, and predisposing factors as well as cognitive and social processing strategies that predict the trajectory of psychological distress and well-being among women diagnosed with gynecological cancer. METHODS: One hundred thirteen women on active treatment for gynecological cancer completed measures at baseline, 3, 6, and 9 months afterward. RESULTS: Women with poorer physician-rated performance status and self-reported functional impairment, women who were Caucasian, women who have received previous psychological treatments, women who were less expressive of positive emotions, women who had unsupportive friends and family, and women who were less able to find something positive in the cancer experience reported poorer adaptation. CONCLUSIONS: This study identified a set of risk factors for poor long-term psychological adaptation among women diagnosed with gynecological cancers. Healthcare professionals working with these women can use these risk factors to screen for patients who may require additional psychological services.

Perceived stress is associated with impaired T-cell response to HPV16 in women with cervical dysplasia.

BACKGROUND: Infection with high-risk subtypes of human papillomavirus (HPV) is a central factor in the development of cervical neoplasia. Cell-mediated immunity against HPV16 plays an important role in the resolution of HPV infection and in controlling cervical disease progression. Research suggests that stress is associated with cervical disease progression, but few studies have examined the biological mechanisms that may be driving this association. PURPOSE: This study examines whether stress is associated with immune response to HPV16 among women with cervical dysplasia. METHODS: Seventy-four women presenting for colposcopy completed measures of health behaviors, stressful life events and perceived stress. A blood sample was obtained to evaluate proliferative T-cell response to HPV16, and a cervical sample was obtained during gynecologic exam for HPV-typing. RESULTS: More than 55% tested positive for one or more HPV subtypes. Women who did not show proliferative responses to HPV (i.e. non-responders) were more likely to be HPV(+) compared to women who had a response (i.e. responders). Consistent with study hypotheses, logistic regression revealed that higher levels of perceived stress were associated with a non-response to HPV16, controlling for relevant covariates. Stressful life events were not associated with T-cell response to HPV. CONCLUSIONS: Higher levels of perceived stress are associated with impaired HPV-specific immune response in women with cervical dysplasia, suggesting a potential mechanism by which stress may influence cervical disease progression.

Coping and communication-enhancing intervention versus supportive counseling for women diagnosed with gynecological cancers.

This study compared the efficacy of 2 psychological interventions, a coping and communication-enhancing intervention (CCI) and supportive counseling (SC), in reducing depressive symptoms and cancer-specific distress of women diagnosed with gynecological cancer. Demographic, medical, and psychological moderators of intervention effects were evaluated. Three hundred fifty-three women with gynecological cancer were randomly assigned to 7 sessions of CCI, 7 sessions of SC, or usual care. Intent-to-treat growth curve analyses indicated that participants assigned to CCI and SC reported lower depressive symptoms than participants assigned to usual care at the 6- and 9-month follow-ups. Women with greater than average increases in physician-rated physical symptoms and/or women who were more expressive of positive emotions benefited more from SC than women with lower than average increases in symptom scores and/or women who were less expressive of positive emotions. These findings suggest that both interventions may be effective in treating depressive symptoms among patients with gynecological cancer. Future research should evaluate whether bolstering both psychological interventions with additional intervention sessions and topics in the disease trajectory will result in persistent long-term effects.

Benign gynecologic conditions among participants in the Breast Cancer Prevention Trial.

OBJECTIVE: This study was undertaken to report on the benign gynecologic conditions occurring among women with an intact uterus at enrollment in the Breast Cancer Prevention Trial of the National Surgical Adjuvant Breast and Bowel Project. STUDY DESIGN: The incidence rates of several benign gynecologic conditions were determined and risks were compared among women receiving tamoxifen and those receiving placebo, based on risk ratios (RRs) with 95% CIs. Comparisons included stratification by menopausal status, body mass index, and history of estrogen use. RESULTS: Compared with women taking placebo, premenopausal women taking tamoxifen had a greater incidence of endometrial polyps (RR = 1.9, 95% CI = 1.55-2.41), leiomyomas (RR = 1.3, 95% CI = 1.14-1.55), endometriosis (RR = 1.9, 95% CI = 1.35-2.70), ovarian cysts (RR = 1.5, 95% CI = 1.20-1.78), and gynecologic surgical procedures, including hysterectomy (RR = 1.6, 95% CI = 1.29-1.88). Postmenopausal women taking tamoxifen also had an increased incidence of endometrial polyps (RR = 2.4, 95% CI = 1.76-3.24), leiomyomas (RR = 1.4, 95% CI = 1.04-1.80), endometriosis (RR = 1.9, 95% CI = 1.29-5.58), and gynecologic surgical procedures, including hysterectomy (RR = 2.2, 95% CI = 1.60-3.13), compared with women taking placebo. All women taking tamoxifen also had an increased incidence of simple endometrial hyperplasia without atypia (overall RR = 2.06, 95% CI = 1.64-2.60) compared with those taking placebo. CONCLUSIONS: Our results strongly support the estrogen agonist role of tamoxifen as the causative factor for the increased risk of endometrial polyps, leiomyomas, endometriosis, and endometrial hyperplasia among women taking this agent.

Ovarian cancer patients' psychological distress: the role of physical impairment, perceived unsupportive family and friend behaviors, perceived control, and self-esteem.

Although research has indicated that illness-related and interpersonal stress are associated with greater psychological distress among cancer patients, little empirical attention has been given to mechanisms that account for these relationships. In the present study, 2 mechanisms for the association between illness-related stress (physical impairment) and interpersonal stress (family and friend unsupportive responses) and psychological distress of 143 ovarian cancer patients were examined cross-sectionally. Separate structural equation models tested whether physical impairment impacted patients' distress via decrements in perceived control over their illness and whether unsupportive behaviors impacted patients' distress via decrements in patients' self-esteem. Results supported the proposed models and suggest that perceived control and self-esteem are 2 mechanisms for explaining how illness-related and interpersonal stress may be associated with psychological distress among women with ovarian cancer.

Tumor cell-specific BRCA1 and RASSF1A hypermethylation in serum, plasma, and peritoneal fluid from ovarian cancer patients.

Because existing surgical and management methods can consistently cure only early-stage ovarian cancer, novel strategies for early detection are required. Silencing of tumor suppressor genes such as p16INK4a, VHL, and hMLH1 have established promoter hypermethylation as a common mechanism for tumor suppressor inactivation in human cancer and as a promising target for molecular detection in bodily fluids. Using sensitive methylation-specific PCR, we screened matched tumor, preoperative serum or plasma, and peritoneal fluid (washes or ascites) DNA obtained from 50 patients with ovarian or primary peritoneal tumors for hypermethylation status of the normally unmethylated BRCA1 and RAS association domain family protein 1A tumor suppressor genes. Hypermethylation of one or both genes was found in 34 tumor DNA (68%). Additional examination of one or more of the adenomatous polyposis coli, p14ARF, p16INK4a, or death associated protein-kinase tumor suppressor genes revealed hypermethylation in each of the remaining 16 tumor DNA, which extended diagnostic coverage to 100%. Hypermethylation was observed in all histologic cell types, grades, and stages of ovarian tumor examined. An identical pattern of gene hypermethylation was found in the matched serum DNA from 41 of 50 patients (82% sensitivity), including 13 of 17 cases of stage I disease. Hypermethylation was detected in 28 of 30 peritoneal fluid DNA from stage IC-IV patients, including 3 cases with negative or atypical cytology. In contrast, no hypermethylation was observed in nonneoplastic tissue, peritoneal fluid, or serum from 40 control women (100% specificity). We conclude that promoter hypermethylation is a common and relatively early event in ovarian tumorigenesis that can be detected in the serum DNA from patients with ovary-confined (stage IA or B) tumors and in cytologically negative peritoneal fluid. Analysis of tumor-specific hypermethylation in serum DNA may enhance early detection of ovarian cancer.

Prevalence and predictors of psychological distress among women with ovarian cancer.

PURPOSE: To identify the prevalence of psychological distress among women with ovarian cancer and to examine the association between these symptoms of distress and demographic and medical variables. PATIENTS AND METHODS: Participants were 143 women with ovarian cancer. Forty-eight percent of participants had been diagnosed with advanced-stage disease (stage III or IV) and most (80%) were currently receiving treatment. Psychological distress was assessed with the following measures: the Beck Depression Inventory, the Mental Health Inventory, the Impact of Events Scale, and a questionnaire regarding mental health service use. RESULTS: Approximately one fifth of women reported moderate to severe levels of distress, and more than half reported high stress responses to their cancer and its treatment. Most participants (60%) were not using any mental health services or psychotropic medications. There was also evidence to suggest that younger patients, patients with more advanced or recurrent disease, and patients who had more recently been diagnosed with ovarian cancer experienced greater psychological distress. CONCLUSION: These findings indicate that psychological distress and high stress responses to cancer are prevalent among women with ovarian cancer, suggesting they should be carefully evaluated to determine whether treatment for these symptoms is warranted.