Use of Coping Strategies and Breast Cancer Survival: Results from the Black/White Cancer Survival Study
Peggy Reynolds1,
Susan Hurley2,
Myriam Torres3,
James Jackson3,
Peggy Boyd2 and
Vivien W. Chen4
1 Environmental Health Investigations Branch, California Department of Health Services, Oakland, CA.
2 Public Health Institute, Berkeley, CA.
3 Institute for Social Research, University of Michigan, Ann Arbor, MI.
4 Department of Public Health and Preventive Medicine, Louisiana State University Medical Center, New Orleans, LA.
 |
ABSTRACT
|
---|
This analysis was designed to evaluate the association between coping strategies and breast cancer survival among Black and White women in a large population-based study. A total of 442 Black and 405 White US women diagnosed with invasive breast cancer during 19851986 and actively followed for survival through 1994 were administered a modified Folkman and Lazarus Ways of Coping questionnaire. Coping strategies were characterized via factor analyses of the responses. Hazard ratios associated with coping strategies were estimated using Cox proportional hazards models, with adjustment for age, race, tumor stage, study location, tumor hormone responsiveness, comorbidity, health insurance status, smoking, relative body weight, and alcohol consumption. Emotion-focused coping strategies were significantly associated with survival. Expression of emotion was associated with better survival (hazard ratio = 0.6; 95% confidence interval: 0.4, 0.9). When it was considered jointly with the presence or absence of perceived emotional support, women reporting low levels of both emotional expression and perceived emotional support experienced poorer survival than women reporting high levels of both (hazard ratio = 2.5; 95% confidence interval: 1.7, 3.7). Similar risk relations were evident for Blacks and Whites and for patients with early and late stage disease. These results suggest that the opportunity for emotional expression may help improve survival among patients with invasive breast cancer. Am J Epidemiol 2000;152:9409.
breast neoplasms; prognosis; psychology; women
Abbreviations:
CI, confidence interval; HR, hazard ratio.
 |
INTRODUCTION
|
---|
Ever since popularization of the notion that women with a "fighting spirit" had better breast cancer survival than women who were compliant (1
), there has been a good deal of research interest in the role that different ways of coping with illness may play in breast cancer prognosis. The "fighting spirit," along with denial, were two psychological responses first identified by British researchers from clinical interviews conducted among 69 early stage breast cancer patients who subsequently experienced better 5-year survival than women whose responses were characterized as "stoic acceptance" or "helplessness/hopelessness" (1
). Follow-up of these patients 10 and 15 years later found the same survival differences as the earlier study (2
, 3
). Similar findings were also reported in 1979 from a small study of 35 women with metastatic breast cancer being treated at the Johns Hopkins Hospital (Baltimore, Maryland) which characterized long term survivors as those who had expressed more negative emotions earlier in their treatment (4
).
Since then, there has been a mix of studies reporting positive (5
) and negative (6



11
) associations. The concept of coping and adaptation to specific stressors such as chronic illness has been intensively evaluated in the psychological literature (12


16
). Most of this research has relied upon small samples of predominately White clinical or community populations. The analysis described here was designed to evaluate the relation between styles of coping and breast cancer survival among Black and White women in a large population-based multicenter study.
 |
MATERIALS AND METHODS
|
---|
Study population
Subjects were selected from breast cancer patients enrolled in the National Cancer Institute's Black/White Cancer Survival Study, a large population-based study designed to investigate racial differences in cancer survival rates. A detailed description of the study's design has been published previously (17
). The study protocol and consent form were approved by the Committee for the Protection of Human Subjects at California's Office of Statewide Health Planning and Development, as well as by the institutional review boards governing the two southern study centers. A total of 1,222 women diagnosed with primary breast cancer between January 1, 1985, and December 31, 1986, were included in the study. The patients were identified through the population-based cancer registries of three US metropolitan areas: Atlanta, Georgia; New Orleans, Louisiana; and San Francisco/Oakland, California. From each metropolitan area, 70 percent of all Black patients with newly diagnosed breast cancer were randomly selected for inclusion. These patients were frequency-matched by age group (2049, 5064, and 6579 years) to newly diagnosed White breast cancer patients who resided within the same metropolitan area.
Coping factor development
Styles of coping were assessed through a series of questions designed to be similar to those in the Folkman and Lazarus Ways of Coping questionnaire (13
). Respondents were asked the extent to which (how often) they used 30 different coping strategies during the month after learning of their diagnosis. We performed factor analysis on these responses in order to reduce the coping measures to conceptually meaningful latent factors (representing distinct strategies of coping). Factor analysis is a statistical procedure used to extract a small number of unifying features from a large number of correlated variables. Initially, we carried out the analysis using an oblique rotation, since it was expected that the factors would be highly intercorrelated. We then used orthogonal and varimax rotations to see whether measures with low loadings could achieve a higher and more acceptable loading using alternative rotations. The final model was tested and improved upon via confirmatory factor analysis. Minor modifications were made to the model to improve its fit, which was within an acceptable range. There were no major differences in fit for Black participants versus White participants.
Through this analysis, we identified seven coping factors; they are described in the Appendix table. Four measures (avoiding people, blaming oneself, getting angry at people, and going along with one's fate) did not load well with any of the factors and were subsequently dropped from the analysis. Using the results of the confirmatory factor analysis, we then computed scores for each patient as weighted means of the elements comprising each factor. To represent the degree to which each patient used a given coping factor, we created indicator variables (high, medium, low) based on the factor distribution (terciles) for the Black/White Cancer Survival Study population. We created a "coping repertoire" variable to investigate whether survival differences existed for women who relied heavily on many different coping strategies versus very few. We composed the coping repertoire variable by summing the number of coping factors for which a patient's score exceeded the median of the study population and created a categorical variable to characterize whether a woman relied heavily on few (01), some (24), or many (57) coping factors.
View this table:
[in this window]
[in a new window]
|
APPENDIX TABLE 1. Elements of coping factors generated by factor analysis performed on valid coping data for all participants, Black/White Cancer Survival Study, 19851986*
|
|
Covariables
Information on covariables was collected from three sources: abstracts of hospital charts supplemented with records from physicians' offices; central pathologic evaluation of breast tumor tissues; and patient interviews. Information on tumor progesterone receptor status, tumor estrogen receptor status, age, and the presence of comorbid conditions at diagnosis was obtained through the medical record abstracts and pathology laboratory results. Progesterone receptor and estrogen receptor status were dichotomized into positive (
10 fmol/mg) and negative/borderline (<10 fmol/mg). Tumor stage was recorded according to the tumor-node-metastasis (TNM) system for breast cancer recommended by the American Joint Committee on Cancer (18
). For this analysis, a summary stage variable was created by dichotomizing stage into early (I, IIN0) and late (IINx, III, IV). Comorbidity information was gathered through an intensive review of the hospital records, supplemented with the office records of the attending physicians. For each patient, a measure of comorbidity was calculated by summing the number of major illnesses mentioned in the medical record thought to potentially influence survival or treatment. The process used for gathering and characterizing the comorbidity information is discussed in greater detail elsewhere (17
, 19
, 20
).
Information on health insurance status, education, family income, emotional support, relative body weight, smoking, and alcohol consumption was obtained from the patient interviews. Level of emotional support was based on a series of questions developed by Seeman and Syme (21
) concerning whether or not patients had resources available (e.g., family, friends, others) for discussing illness and other personal problems. The role of treatment in breast cancer survival in this study population is discussed elsewhere (19
). Based on these earlier findings, we did not incorporate treatment information into this analysis because the data were not sufficiently complete (especially for chemotherapy) and the earlier analysis found that after adjustment for tumor stage, treatment did not independently predict breast cancer survival in this study population (19
). While most interviews (60 percent) were conducted within 3 months of diagnosis, we created a variable to represent the time interval from diagnosis to interview. All patients were asked about the coping strategies they had used during the first month after learning of their diagnosis. We used this time-since-diagnosis variable to investigate whether the recall of those strategies differed by the amount of time that had elapsed since diagnosis.
Follow-up data
Follow-up information was obtained from the Surveillance, Epidemiology, and End Results database for San Francisco-Oakland and Atlanta and was obtained under special contract with the National Cancer Institute for New Orleans. Breast cancer deaths were defined as those with International Classification of Diseases, Ninth Revision, code 174 listed as the underlying cause of death. Survival time (in months) was calculated from the date of diagnosis to the date of death or the most recent follow-up. Patients who died of causes other than breast cancer during the follow-up period were counted as having withdrawn from the study at the time of death, and their data were treated as censored in the survival analysis. Because Surveillance, Epidemiology, and End Results data for all three regions were considered complete only through the end of 1994, survival time was truncated at December 31, 1994.
Analysis
Race and stage differences in coping styles were examined using frequency tables and
2 tests for independence. The relation between reported coping strategies and the time that had elapsed between diagnosis and interview was explored in several ways. Scatterplots, Spearman rank correlations, and cross-tabulations of categorized data with
2 statistics offered no evidence that the distribution of coping factors varied by time from diagnosis to interview. Multivariate Cox regression models were used to investigate the relation between coping strategies and breast cancer survival. Each coping factor was considered separately, and all initial models included adjustment for design variables (age, study location), race, and summary stage. In subsequent models, further adjustments were made for comorbidity, relative body weight, progesterone receptor and estrogen receptor status, time from diagnosis to interview, alcohol consumption, smoking, and type of health insurance. To assess whether risk estimates differed by race (Blacks vs. Whites) or tumor stage (late stage vs. early stage), we stratified the data according to these factors and repeated the regression analyses.
The Cox regression analyses were carried out using the PHREG procedure in SAS (22
). Examination of Kaplan-Meier survival curves and log-minus-log survival plots indicated no apparent violation of the underlying assumption of proportional hazards upon which the Cox regression model is predicated (23
, 24
).
 |
RESULTS
|
---|
By the end of the follow-up period, there had been 218 deaths due to breast cancer (137 among Blacks and 81 among Whites). The median duration of follow-up for women who had not died of breast cancer was 107 months. Median durations of follow-up did not differ by race.
For the purposes of this analysis, only women for whom completed interview information was available were considered eligible. Of the 1,222 women identified with invasive breast cancer, 1,013 completed the interview, for an overall response rate of 83 percent. Response rates did not differ substantially between Blacks (81.2 percent) and Whites (84.8 percent). Reasons for nonparticipation included physician refusal (2.9 percent); the physician's being ill or deceased or having moved (2.0 percent); patient refusal (7.4 percent); the patient's being ill or deceased or having moved (3.1 percent); and other miscellaneous reasons (1.8 percent). Furthermore, patients were excluded from this analysis if they had in situ cancer (n = 89), unknown vital status at the last follow-up (n = 2), unknown stage at diagnosis (n = 36), or missing data on coping questions (n = 39). Thus, the survival analysis was conducted with a sample of 847 women, 442 (52.2 percent) of whom were Black and 405 (47.8 percent) of whom were White.
The distributions of selected covariates are shown in table 1. With the exception of age (which was a matching variable), Blacks and Whites differed with regard to all characteristics examined. Compared with Whites, Blacks were more likely to have low socioeconomic status indicators, late stage disease, estrogen receptor negative and progesterone receptor negative tumors, comorbidity at diagnosis, and a high body mass index and were more likely to be current smokers. However, Blacks were less likely to drink alcohol.
Racial and stage differences in coping
Blacks appeared to use a substantially different constellation of coping strategies than Whites. As table 2 illustrates, the distributions for all coping factors except avoidance varied significantly by race. Blacks were more likely to rely heavily on suppressing emotions, wishful thinking, and positive reappraisal, while Whites were more apt to use higher levels of expressing emotions, problem-solving, and escapism.
View this table:
[in this window]
[in a new window]
|
TABLE 2. Distribution of coping factors among women diagnosed with invasive breast cancer, by race and tumor stage at diagnosis, Black/White Cancer Survival Study, 19851986
|
|
With the exception of avoidance, which was somewhat more common among patients with early stage disease, the distributions of coping factors did not differ significantly by stage (table 2). Likewise, coping repertoires did not vary by race or by stage of disease (table 3).
View this table:
[in this window]
[in a new window]
|
TABLE 3. Distribution of repertoires of coping strategies among women diagnosed with invasive breast cancer (n = 847), Black/White Cancer Survival Study, 19851986
|
|
Coping and breast cancer survival
The adjusted hazard ratios for breast cancer mortality associated with each of the coping factors are presented in table 4. After adjustment for age, study location, race, and summary stage of disease, emotion-focused coping strategies were significantly associated with risk of breast cancer mortality. The Pearson correlation coefficient for expression and suppression of emotions was 0.51. Expression of emotion was related to better survival (hazard ratio (HR) = 0.6; 95 percent confidence interval (CI): 0.4, 0.9), and suppression of emotion was associated with worse survival (HR = 1.4; 95 percent CI: 1.1, 1.9). These effects were generally consistent across race and stage of disease. The hazard ratios for all other coping factors did not differ significantly from 1. Further adjustment for comorbidity, relative body weight, progesterone receptor and estrogen receptor status, time from diagnosis to interview, alcohol consumption, smoking, education, income, and type of health insurance did not substantially change these results (data not shown). Education, income, and type of health insurance were all highly correlated with race. In multivariate models that included race, type of health insurance was the only socioeconomic variable that remained statistically significant. The hazard ratio for a medium level of wishful thinking among Whites was significantly less than 1 (HR = 0.5; 95 percent CI: 0.3, 0.9) (table 4). The lack of an effect at high levels of wishful thinking and the lack of consistency among other subgroups suggests that this finding was probably an artifact of chance.
View this table:
[in this window]
[in a new window]
|
TABLE 4. Association between coping factors and risk of breast cancer mortality among women with invasive breast cancer, Black/White Cancer Survival Study, 19851994*
|
|
Hazard ratios estimating the effect of coping repertoire on breast cancer survival (adjusted for design variables, race, and stage) are presented in table 5. These results suggest that patients who rely on many coping strategies may have a modest survival advantage over women who use very few strategies (HR = 0.7; 95 percent CI: 0.4, 1.0). Stratification of the data suggested that this relation may be limited to Whites (HR = 0.4; 95 percent CI: 0.2, 0.8). Further adjustment of the models for progesterone receptor and estrogen receptor status, relative body weight, type of health insurance, comorbidity, smoking, and alcohol consumption did not change these results.
View this table:
[in this window]
[in a new window]
|
TABLE 5. Association between repertoire of coping strategies and risk of breast cancer mortality among women with invasive breast cancer, Black/White Cancer Survival Study, 19851994*
|
|
An earlier analysis of survival carried out in this population (25
) found that women who perceived low levels of emotional support had worse 5-year breast cancer survival rates than women with high levels of emotional support (HR = 1.8; 95 percent CI: 1.3, 2.5). Using the most recent follow-up data, we reexamined this relation and confirmed this earlier finding (HR = 1.7; 95 percent CI: 1.3, 2.3). Given that the current analysis suggested emotion-focused strategies to be the most important coping-related predictors of survival, we further investigated this relation in the context of emotional support. These results, shown in table 6 and figure 1, suggest that the effects of emotional expression vary according to the level of perceived emotional support. The log-likelihood ratio test for interaction indicated that the interaction between these two variables was statistically significant (
2 = 27.0, p < 0.01). Patients who reported low levels of emotional expression in conjunction with low levels of emotional support experienced worse survival than women who reported high levels of both (HR = 2.5; 95 percent CI: 1.7, 3.7). Although similar risk relations were evident among Blacks, Whites, and women with late stage disease, the risk was more pronounced among women with early stage tumors. These patients had a nearly fourfold risk of dying from breast cancer if they reported low levels of both emotional expression and emotional support when compared with patients with early stage tumors who reported high levels of both (HR = 3.9; 95 percent CI: 1.5, 10.0).
View this table:
[in this window]
[in a new window]
|
TABLE 6. Risk of breast cancer mortality associated with the joint distribution of emotional expression and emotional support, Black/White Cancer Survival Study, 19851994*
|
|

View larger version (11K):
[in this window]
[in a new window]
|
FIGURE 1. Breast cancer survival among women diagnosed with invasive breast cancer in the Black/White Cancer Survival Study (January 1, 1985December 31, 1986), by level of emotional expression and emotional support. Data were adjusted for age, race, and tumor stage using Cox proportional hazards models. , high support and high expression; . . . ., mixed levels of support and expression (high support with low/medium expression or low support with high expression); . . , low support and low/medium expression.
|
|
Explaining the Black/White difference in breast cancer survival was not the primary focus of this analysis. However, our results suggest that differences in coping strategies used by Black and White women do not contribute much to an explanation of the survival differential. The multivariate analysis conducted without the coping variables produced a hazard ratio for race (i.e., for being Black) of 1.7 (95 percent CI: 1.3, 2.2). When emotional expression was added to the model, the hazard ratio did not change substantially and remained statistically significant (HR = 1.6; 95 percent CI: 1.2, 2.1).
 |
DISCUSSION
|
---|
This large population-based study offered provocative evidence that the opportunity for emotional expression may have a positive prognostic value for breast cancer patients. Evaluation of these findings in the context of perceived emotional support, which was demonstrated to be positively associated with survival in an earlier report from this study (25
), produced even more striking results. Notably, women in our study who reported low levels of both emotional expression and emotional support experienced 24 times greater breast cancer mortality than women reporting high levels of both.
There are a number of difficulties involved in making direct comparisons of our study results with those from the literature on this topic. These include differences in measures of coping or psychological response, the tumor characteristics of the patients studied, the availability of data on important covariables, follow-up periods, outcome measures, and analytic strategies. Most studies have used either clinical interviews (1
, 3
, 7
, 9
, 26
, 27
) or standard psychometric instruments (4
6
, 8
, 10
, 11
, 27






35
) designed primarily to measure psychopathology, rather than measures of normal variations in responsiveness. Rarely is the same instrument used, however, so replication of results is open to considerable interpretation. Case series tend to be small and are inevitably drawn from clinic populations that may or may not be relatively homogeneous with regard to cancer type and stage (1
, 3
, 5
, 8

11
, 26
, 28
, 30
, 31
). Few studies have been able to adjust for other prognostic factors that might influence the course of disease (3
, 5
, 7
, 9
, 11
, 31
, 34
, 36
, 37
). Some studies have considered survival time (3
, 7
, 9
10
11
, 34
, 37
, 38
) and others have considered time to recurrence (1
3
, 5
, 6
, 9
, 34
). Studies of patients with metastatic disease tend to compare short term survival (less than 1 year) with long term survival (4
, 8
, 35
). Many of these investigations recruit patients into the study 6 or more months after diagnosis, introducing a built-in survival bias (36
). Many analyses are based on simple comparisons of mean values, correlation coefficients, and other univariate statistical procedures (1
, 2
, 4
6
, 8
, 10
, 26
, 35
). These procedures, unlike Cox proportional hazards modeling, do not allow for adjustment for other important prognostic factors, nor do they take into account censoring of the survival data; hence, they provide a less precise estimate of risk. Review articles on psychological interventions generally agree that the diversity of study designs and the general focus on short term outcomes make it difficult to assess the evidence for such programs' influencing cancer survival (39
, 40
).
The timing of assessment and outcome measures used may be particularly important features to consider when evaluating the literature on this topic. One study which collected data from repeated measures of coping in breast cancer patients over a 3-year period suggested that there were substantial changes in coping strategies over time, but the authors offered few supporting details (10
). Conflicting but more convincing evidence comes from a study which examined both measures of affective distress and cortisol metabolites in breast cancer patients followed for 10 years and reported stable values for both (26
). A recent 5-year study of 74 breast cancer patients in which coping strategies were reassessed every 36 months found that coping strategies varied but that this variability was more strongly related to illness-related events (e.g., hospitalization, rehabilitation, recurrence) than to time since diagnosis (41
). This is an important area of uncertainty that the current analysis could not address. While we saw little evidence of differences in coping strategies based on stage at diagnosis or time from diagnosis to interview, we were unable to assess whether and how patients may have changed their coping strategies during the follow-up period. The results presented in this report are based on the coping strategies used during the month following diagnosis. We do not know, for instance, if those women who experienced a recurrence of their disease changed their coping strategies and how those changes may have affected their survival. This is an important issue worthy of future study.
Cohen and Lazarus (12
, 42
) have emphasized that coping is a process rather than a trait. As such, it can only be evaluated in the context of a particular situation and in the context of the demands and resources that come with that situation (12
). There is evidence that people are more likely to use emotion-based coping strategies in health contexts (14
). Similarly, coping which may be adaptive to short term outcomes is not necessarily adaptive to long term outcomes. There are a number of studies suggesting that emotion-based coping may be associated with poorer disease adaptation (28
, 43
) but better long term survival (12
). While we were not able to evaluate the former possibility, our results support the latter.
Despite the difficulties in comparing study results on this topic, the literature does offer a number of threads of evidence which are consistent with the importance of emotion-based coping for women with breast cancer. Greer and Morris (27
) found that patients diagnosed with breast cancer were more likely to have shown both extreme suppression and extreme expression of emotion during a preoperative interview than patients who were subsequently determined to have benign breast disease. In the Johns Hopkins Hospital study, it was the women whom clinicians identified as poorly adjusted to their illness who experienced longer survival (4
). In an interesting study of psychological correlates of natural killer cell activity, Levy et al. (44
) observed that the patients with low levels of natural killer cell activity were "well adjusted" to their illness, while patients with high levels were those who were distressed or "maladjusted." Speigel et al. (38
), in reporting on their work with advanced stage breast cancer patients at Stanford University, reported significant differences in survival in favor of women randomized to an intervention group which emphasized support and expression of feelings. Temoshok et al. (45
) reported that suppression of emotional responses is a central characteristic of the stoic, accepting, and compliant "Type C" personality, which is associated with poorer prognosis in their studies of melanoma patients. Together, these studies and ours, like those of the British investigators (1
3
), suggest that coping strategies which make for a compliant patient who is well adjusted to her illness may be maladaptive for long term survival.
The current study had some notable strengths that addressed a number of limitations common to many previous investigations on this topic. The study population was large and population-based, and one of the few to include Black patients. Furthermore, extensive data were available on other well recognized prognostic factors for breast cancer. Therefore, we were able to adjust our estimates of coping-related risk for many important covariates that previous studies have not been able to adjust for. Considered in the context of other prognostic features, these data suggest that the combination of strong emotional support and an opportunity to express emotions may have a beneficial effect on survival from breast cancer.
 |
ACKNOWLEDGMENTS
|
---|
This research was supported in part by National Cancer Institute contracts N01-CN45176 and N01-CN05247.
 |
NOTES
|
---|
Reprint requests to Dr. Peggy Reynolds, California Department of Health Services, 1515 Clay Street, Suite 1700, Oakland, CA 94612 (e-mail: PReynolds{at}dhs.ca.gov).
 |
REFERENCES
|
---|
-
Greer S, Morris T, Pettingale KW. Psychological response to breast cancer: effect on outcome. Lancet 1979;2:7857.[Medline]
-
Pettingale KW. Coping and cancer prognosis. J Psychosom Med 1984;28:3634.
-
Greer S. Psychological response to cancer and survival. Psychol Med 1991;21:439.[ISI][Medline]
-
Derogatis LR, Abeloff MD, Melisaratos N. Psychological coping mechanisms and survival time in metastatic breast cancer. JAMA 1979;242:15048.[Abstract]
-
Jensen MR. Psychobiological factors predicting the course of breast cancer. J Pers 1987;55:31742.[ISI][Medline]
-
Cassileth BR, Lusk EJ, Miller DS, et al. Psychosocial correlates of survival in advanced malignant disease. N Engl J Med 1985;312:15515.[Abstract]
-
Cassileth BR, Walsh WP, Lusk EJ. Psychosocial correlates of cancer survival: a subsequent report 3 to 8 years after cancer diagnosis. J Clin Oncol 1988;6:17539.[Abstract]
-
Jamison RN, Burish TG, Wallston KA. Psychogenic factors in predicting survival of breast cancer patients. J Clin Oncol 1987;5:76872.[Abstract]
-
Dean C, Surtees PG. Do psychological factors predict survival in breast cancer? J Psychosom Res 1989;33:5619.[ISI][Medline]
-
Buddeberg C, Wolf C, Seiber M, et al. Coping strategies and course of disease of breast cancer patients: results of a 3-year longitudinal study. Psychother Psychosom 1991;55:1517.[ISI][Medline]
-
Buddeberg C, Sieber M, Wolf C, et al. Are coping strategies related to disease outcome in early breast cancer? J Psychosom Res 1996;40:25564.[ISI][Medline]
-
Cohen F, Lazarus RS. Coping and adaptation in health and illness. In: Mechanic D, ed. Handbook of health, health care, and the health professions. New York, NY: The Free Press, 1983:60835.
-
Folkman S, Lazarus RS. An analysis of coping in a middle-aged community sample. J Health Soc Behav 1980;21:21939.[ISI][Medline]
-
Folkman S, Lazarus RS, Dunkel-Schetter C, et al. Dynamics of a stressful encounter: cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol 1986;50:9921003.[ISI][Medline]
-
Folkman S, Lazarus RS, Pimley S, et al. Age differences in stress and coping processes. Psychol Aging 1987;2:17184.[ISI][Medline]
-
Vitaliano PP, Russo J, Carr JE, et al. The Ways of Coping checklist: revision and psychometric properties. Multivariate Behav Res 1985;20:326.[ISI]
-
Howard J, Hankey BF, Greenberg RS, et al. A collaborative study of differences in the survival rates of black patients and white patients with cancer. Cancer 1992;69:234960.[ISI][Medline]
-
Beahrs OH, Myers MH, eds. Manual for staging of cancer. 2nd ed. Philadelphia, PA: J B Lippincott Company, 1983.
-
Eley JW, Hill HA, Chen VW, et al. Racial differences in survival from breast cancer: results of the National Cancer Institute Black/White Cancer Survival Study. JAMA 1994;272:94754.[Abstract]
-
Coates RJ, Clark WS, Eley JW, et al. Race, nutritional status and survival from breast cancer. J Natl Cancer Inst 1990;82:168492.[Abstract]
-
Seeman T, Syme SL. Social networks and coronary artery disease: a comparison of the structure and function of social relations as predictors of disease. Psychosom Med 1987;49:34154.[Abstract]
-
SAS Institute, Inc. Proc PHREG. In: SAS, version 6.12. Cary, NC: SAS Institute, Inc, 1991.
-
Katz MH, Hauck WW. Proportional hazards (Cox) regression. J Gen Intern Med 1993;8:70211.[ISI][Medline]
-
Cox D. Regression models and life tables (with discussion). J R Stat Soc [B] 1972;34:187220.[ISI]
-
Reynolds P, Boyd PT, Blacklow RS, et al. The relationship between social ties and survival among black and white breast cancer patients. Cancer Epidemiol Biomarkers Prev 1994;3:2539.[Abstract]
-
Gorzynski JG, Holland J, Katz JL, et al. Stability of ego defenses and endocrine responses in women prior to breast biopsy and ten years later. Psychosom Med 1980;42:3238.[Abstract]
-
Greer S, Morris T. Psychological attributes of women who develop breast cancer: a controlled study. J Psychosom Res 1975;19:14753.[ISI][Medline]
-
Bombardier CH, D'Amico CD, Jordan JS. The relationship of appraisal and coping to chronic illness adjustment. Behav Res Ther 1990;28:297304.[ISI][Medline]
-
Hilton BA. The relationship of uncertainty, control, commitment, and threat of recurrence to coping strategies used by women diagnosed with breast cancer. J Behav Med 1989;12:3953.[ISI][Medline]
-
Leigh H, Ungerer J, Percarpio B. Denial and helplessness in cancer patients undergoing radiation therapy: sex differences and implications for prognosis. Cancer 1980;45:30869.[ISI][Medline]
-
Razavi D, Farvacques C, Delvaux N, et al. Psychosocial correlates of oestrogen and progesterone receptors in breast cancer. Lancet 1990;335:9313.[ISI][Medline]
-
Richardson JL, Zarnegar Z, Bisno B, et al. Psychological status at initiation of cancer treatment and survival. J Psychosom Med 1990;34:189201.
-
Rogentine NG, van Kammen DP, Fox BH, et al. Psychological factors in the prognosis of malignant melanoma: a prospective study. Psychosom Med 1979;41:64755.[Abstract]
-
Tross S, Herndon JI, Korzun A, et al. Psychological symptoms and disease-free and overall survival in women with stage II breast cancer. J Natl Cancer Inst 1996;88:6617.[Abstract/Free Full Text]
-
Tuls Halstead M, Fernsler JI. Coping strategies of long-term cancer survivors. Cancer Nurs 1994;17:94100.[ISI][Medline]
-
Morgenstern H, Gellert GA, Walter SD, et al. The impact of a psychosocial support program on survival with breast cancer: the importance of selection bias in program evaluation. J Chronic Dis 1984;37:27382.[ISI][Medline]
-
Pettingale KW, Morris T, Greer S, et al. Mental attitudes to cancer: an additional prognostic factor. (Letter). Lancet 1985;1:750.[ISI][Medline]
-
Spiegel D, Bloom JR, Kraemer HC, et al. Effect of psycho-social treatment on survival of patients with metastatic breast cancer. Lancet 1989;2:88891.[ISI][Medline]
-
Trijsburg RW, van Knippenberg FC, Rijpma SE. Effects of psychological treatment on cancer patients: a critical review. J Psychosom Med 1992;54:489517.
-
Anderson BL. Psychological interventions for cancer patients to enhance the quality of life. J Consult Clin Psychol 1992;60:55268.[ISI][Medline]
-
Heim E, Valach L, Schaffner L. Coping and psychosocial adaptation: longitudinal effects over time and stages in breast cancer. Psychosom Med 1997;59:40818.[Abstract]
-
Cohen F, Lazarus RS. Coping with the stresses of illness. In: Stone GC, Cohen F, Adler NE, eds. Health psychology: a handbook. San Francisco, CA: Jossey-Bass Publishers, 1979.
-
Koller M, Kussman J, Lorenz W, et al. Symptom reporting in cancer patients: the role of negative affect and experienced social stigma. Cancer 1996;77:98395.[ISI][Medline]
-
Levy SM, Herberman RB, Maluish AM, et al. Prognostic risk assessment in primary breast cancer by behavioral and immunological parameters. Health Psychol 1985;4:99113.[ISI][Medline]
-
Temoshok L, Heller BW, Sagebiel RW, et al. The relationship of psychosocial factors to prognostic indicators in cutaneous malignant melanoma. J Psychosom Res 1985;29:13953.[ISI][Medline]
Received for publication May 13, 1999.
Accepted for publication February 4, 2000.