Predictors of quality of life in newly diagnosed melanoma and breast cancer patients

U.-S. Lehto1,*, M. Ojanen2 and P. Kellokumpu-Lehtinen3

1 University of Tampere, Medical School, Oncology, and 2 Department of Psychology, Tampere; 3 University of Tampere, Medical School, Oncology, Tampere University Hospital, Department of Oncology, Tampere, Finland

* Correspondence to: Dr U.-S. Lehto, National Public Health Institute KTL, Department of Health and Functional Capacity, Mannerheimintie 166, FIN-00300 Helsinki, Finland. Tel: +358-9-4744-8797; Fax: +358-9-4744-8924; Email: ulla-sisko.lehto-jarnstedt{at}ktl.fi


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Appendix 1. Items included...
 References
 
Background:: Quality of life (QoL) is a multidimensional construct, and several psychosocial and medical factors can predict a patient's QoL. We investigated the impact of factors in the psychological stress processes on QoL 3 months after diagnosis of melanoma or breast cancer.

Patients and methods:: In consecutive melanoma and breast cancer patients with localized disease, cancer-specific social support, coping with cancer, personality trait anger expression, non-cancer stress, sociodemographic variables, cancer and treatment variables, and QoL (evaluated as self-reported psychological and physical symptoms, self-perceived QoL, and depression) were assessed with validated quantitative questionnaires. The associations between QoL and the other factors were investigated with multivariate methods.

Results:: Only a few factors differed between melanoma and breast cancer, in terms of treatment modalities and gender. The amount of received social support was higher among breast cancer patients. The predicting power of psychological stress factors on all the QoL measures was strong, but differed between the treatment groups (surgery only versus adjuvant treatment). Psychosocial factors were the strongest predictors of QoL, not cancer type or treatment. Behavioral Escape-Avoidance coping was associated with worse QoL. However, non-cancer life stresses showed the strongest QoL-decreasing influence. QoL-enhancing factors, including social support, were seen clearly only within the breast cancer patients receiving adjuvant treatment.

Conclusions:: QoL of newly diagnosed cancer patients is highly associated with psychosocial factors. Non-cancer life stresses seem to be very important in the QoL of newly diagnosed cancer patients. Adjuvant treatment may comprise supportive psychosocial factors that enhance QoL in cancer.

Key words: coping, life change events, psychological stress, quality of life, social support, symptoms


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Appendix 1. Items included...
 References
 
Owing to the fact that success of treatment in prolonging life is a mixed blessing—it is not enough to survive, patients also want to live [1Go]— quality of life (QoL) is presently an important outcome factor in oncological research [2Go, 3Go]. QoL and its components and determinants have received growing interest [3Go–8Go], and physical, mental and social well-being have, with varying levels of emphasis and in various combinations, been included in the concept [1Go, 4Go, 9Go, 10Go]. In a recent model for guiding psycho-oncological research [2Go], the independent factors of the psychobiological process were stated to consist of: (i) cancer and its treatment; and (ii) the mediating factors in four major categories of variables: personal (including sociodemographic factors, personality and coping style), medical, social and life stresses. These are proposed to result in the outcome, which consists of both QoL and survival. Psychosocial interventions are presumed to be capable of, and the means to, changing the mediating factors and thereby the QoL outcomes [2Go, 11Go–14Go].

According to psychological stress theories, the effects of stress on health outcomes depend on how a person can cope with the stress, coping being the main mediator in the process from stressful events to outcomes such as psychological symptoms and somatic illness [15Go–17Go]. Social support and personality factors modify the coping process [18Go]: support protects individuals from the potentially harmful effects of stress [19Go] and personality is associated with coping behavior of the person. In the process-oriented view [15Go–18Go], coping is defined as ‘the person's constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the person's resources.’ Coping is a process and contextual, and there are no assumptions on good or bad coping. The actual coping process refers to the person's efforts to reduce, minimize, master or tolerate the person–environment transaction that has been appraised to be demanding. Psychological stress processes have been linked with biological immune down-regulation in cancer [20Go].

Social support is an interactive process in which particular actions or behaviors may positively affect an individual's social, psychological or physical well-being [19Go, 21Go]. Social support affects health by producing benign appraisal of stressful events, improving coping, preventing stress-induced biological and behavioral responses, suppressing neuroendocrine responses to stress, enhancing immune function, and increasing healthy behavior and health maintenance [22Go]; it has been suggested to be a key psychosocial mediator in cancer [23Go]. Social support is derived from the social network [21Go, 24Go], and is issue-specific when it has been received in a certain context.

Personality factors per se do not help anyone to overcome cancer, but personality influences stress and coping processes. The main elements of personality pattern ‘type C behavior’ developed in cancer research are suppression of emotional responses, particularly anger and fear, and inappropriate coping mechanisms [25Go, 26Go]. Potentially stressful situations may be more threatening for people with type C pattern, because they cannot allow themselves to express negative emotions.

In addition to the cancer, there may be various non-cancer stressors in the life of a patient. These may include life events referring to external verifiable changes [27Go] or chronic strains, which are persistent conditions that require daily readjustment [19Go, 28Go]. Stressors disrupt routine activities, either acutely or chronically, and initiate the coping processes.

QoL is an all-encompassing and subjective concept [5Go] and its definitions and the subconcepts involved have varied [1Go]. In a simple way, QoL has been defined as the ‘subjective evaluation of life as a whole’ [29Go], or ‘the patients’ appraisal and satisfaction with their current level of functioning compared with what they perceive to be possible or ideal [5Go]. Explicitly, QoL is ‘a multidimensional construct encompassing perceptions of both positive and negative aspects of dimensions such as physical, emotional, social and cognitive functions, as well as the negative aspects of somatic discomfort and other symptoms produced by a disease or its treatment’ [10Go].

In the present paper, we assume that the QoL in cancer patients is influenced by psychological stress processes (Figure 1). These processes include coping with cancer, which is modified by social support and personality, initiated by cancer-related stressors, and interfered with by non-cancer life stress. We have evaluated these psychosocial factors and QoL in melanoma and breast cancer patients with localized disease 3–4 months after diagnosis. We investigated the power of these psychosocial factors and sociodemographic factors, cancer type (melanoma, breast cancer), and treatment modality to predict the QoL of the patients.



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Figure 1. Psychological stress processes in cancer [31Go].

 

    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Appendix 1. Items included...
 References
 
Patients
The basic study population consisted of melanoma and breast cancer patients 28–71 years of age with localized disease who were newly diagnosed and admitted for treatment and/or follow-up to the Oncology Clinic of Tampere University Hospital (Finland) from June 1995 to May 1998 (melanoma) or from January to September 1996 (breast cancer). Cancer care is centralized in Finland, thus nearly all patients diagnosed in the hospital district in question could be consecutively included in the group of eligible patients. The oldest (>71 years) and youngest (<28 years) patients were excluded, owing to differences in social support between age groups or stages in the life cycle. In adolescence, social relationships undergo dramatic changes and the support functions typical for adults take shape, while at the other end of the life cycle, the elderly begin to need more practical support than other adults. In situ melanomas were included because the treatment and follow-up procedures were similar to those of other melanoma patients. In situ breast cancers were excluded. Nearly one-third of the patients were >71 years of age; these were not included in the basic study group.

Two breast cancer patients were excluded, owing to chronic schizophrenia and consequent difficulty in understanding the nature of their disease or treatment. One melanoma patient and two breast cancer patients were excluded for having had cancer previously, which was hypothesized to have influenced the psychological stress processes of the disease. The remaining patients (n=84 + 126) were invited to participate in the study, first by letter and later by personal contact either from the first author or a research nurse. In all, 86% of the invited melanoma patients and 82% of the invited breast cancer patients were willing to participate.

The final study group consisted of 72 melanoma patients [70 non-metastatic (those patients with metastases were taken for interview before it was known that the disease was not localized), eight had in situ tumor] and 103 breast cancer patients (102 non-metastatic). The patients who declined had approximately the same age and disease variable distributions as those in the study group. Disease and treatment variables are presented in Table 1. In the total sample, 56% of the patients (n=98) had only had surgery, while 44% (n=76) also received adjuvant treatment(s). None of the patients received psychosocial intervention.


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Table 1. Sociodemographic and disease variables in patients, by cancer type

 
The mean age of the patients was 55 and 54 years for melanoma and breast cancer patients, respectively, but the range was wider for melanoma (standard deviations 12.1 and 8.5, respectively). Female melanoma patients were slightly younger than males (mean ages 51 and 58 years). Sociodemographic factors of the patients are presented in Table 1.

Methods
The patients were clinically interviewed following a specific structural format by the same psychologist (the first author) 3–4 months after diagnosis. The interviewees completed several structured validated questionnaires, indicating presence, frequency or intensity of variables in the stress processes or QoL. By domain, the measures used were: coping with cancer, Ways of Coping Questionnaire (WOC) [30Go]; cancer-specific social support, Structural–Functional Social Support Scale (SFSS) [31Go, 32Go]; type C-related anger expression, Anger Expression (AX) scale [33Go]; non-cancer stressors, Life Experience Survey (LES) [27Go] and Chronic Strains Survey (CSS) [31Go]. As outcome factors, perceived symptoms and well-being were measured, indicating QoL by the Rotterdam Symptom Checklist (RSCL) [29Go], the Depression Scale (DEPS) [34Go] and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire's (EORTC QLQ) breast cancer (Br23) module [35Go].

The WOC is a self-report questionnaire developed ‘to identify the thoughts and actions an individual has used to cope with a specific stressful encounter’ (here, any aspect of cancer). We used the 50-item scale. Five coping patterns of were identified: focusing on the positive, distancing, seeking social support, cognitive escape-avoidance and behavioral escape-avoidance, as presented previously [36Go, 37Go].

The SFSS measures cancer-specific social network and social support received from it. In the first part, patients are asked to indicate, from a maximum of 10 groups of people (spouse, family, relatives, fiends, acquaintances, other patients, physicians, nurses and two optional sources), the number of persons with whom they have had contact and who have been aware of their disease. The second part measures the support received using a 10-item questionnaire that is completed separately for each of the sources mentioned; the items of the questionnaire are derived from a qualitative study by Dakof and Taylor [24Go].

Personality factors were measured in the context of the theory of cancer-prone type C personality with AX scale (24 items). It refers to ‘the extent that an individual engages in aggressive behaviors when motivated by angry feelings’, and taps 3 dimensions: anger-in (individual differences in the frequency that angry feelings are experienced but held in), anger-out (feelings of anger are expressed in aggressive behaviour), and anger control (an individual attempts to control the outward expression of angry feelings).

Stressful life events were measured from the year preceding the interview by the LES, a list of 50 events addressing both the number of life events and their perceived impact (scale –3 to +3). The more persistent stressful conditions were evaluated by the CSS (13 items, by authors), the items concerning the existence and perceived burden of economical and social difficulties, strains in work life, alcohol or drug abuse, other chronic diseases, etc., with a scale of 0–3 for every strain.

To measure patients' symptoms and their intensity we used the RSCL, which was developed to measure symptoms reported by cancer patients. RSCL includes 30 symptoms the patients may have experienced during the last week. RSCL measures both psychological and physical symptoms. In addition, ‘perceived quality of life’ is evaluated by a single-item index.

Depressive symptoms were evaluated by the DEPS, developed to screen depression in Finnish primary health-care settings. DEPS is a self-report scale with 10 items, each with a scale of 0 (not at all) to 3 (extremely), and with a coverage period of the previous month.

Breast cancer patients also completed the EORTC QLQ-Br23 questionnaire, the breast cancer module of EORTC QLQ questionnaire.

Evaluations of coping (WOC) and cancer-specific social support (SFSS) covered the entire period following diagnosis. Sociodemographic variables were also recorded. Information on the disease and treatment was collected from hospital records. The Ethical Committee of Tampere University Hospital approved the research protocol.

The structure and psychometric properties of the questionnaires and their subscales were analyzed. The scales were normally distributed. The psychometric properties of the measures were sufficient or good. Group differences in the scales were investigated by t-test and ANOVA. We created a model (Figure 1) based on the hypothesized connections of the variables obtained in the literature and along with the correlation analyses (Pearson's correlation coefficient, r) of the data [31Go]. The ability of the factors to predict QoL was investigated by using stepwise regression analyses. A separate model was created to investigate predictors of four different domains of QoL: psychological symptoms, physical symptoms, perceived well-being and depressive symptoms, and in addition, two breast cancer-specific symptom groups. A probability level of 0.05 was used for statistical significance. The statistical package used was SPSS for Windows, version 11.


    Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Appendix 1. Items included...
 References
 
Factors in the psychological stress process
Cancer diagnosis. Impact of the cancer diagnosis was indicated as extremely negative by 45% of the patients and as moderately negative by 26%; the remaining patients saw it either as mildly negative or not negative at all. There were no gender differences. The impact was less negative among patients undergoing only surgery and most negative among patients undergoing chemotherapy (F=7.82, P=0.001). Younger breast cancer patients experienced the diagnosis more negatively than older partients (rho=0.20, P=0.49). A more positive impact of non-cancer life events (total change score) was associated with less negative impact of diagnosis (rho=0.25, P=0.037 in melanoma; rho=0.37, P <0.001 in breast cancer).

Coping with cancer. Of the five coping patterns identified, >90% of the patients used the first four (patients had scored >0 in any item of this pattern), while behavioral escape-avoidance was used by only ~70% of the patients (Table 2). The homogeneities were satisfactory (Table 2). The most intensively used coping pattern for both melanoma and breast cancer was seeking social support. Patients in both cancer and gender groups used the coping patterns to the same extent except for seeking social support, which was used more in breast cancer (P <0.001) and more by female than male melanoma patients (P <0.001). The patterns of coping with breast cancer did not differ by cancer treatment. In melanoma, older patients were less active copers than younger patients in terms of all patterns except cognitive escape-avoidance. In breast cancer, age had no association with coping.


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Table 2. Levels of coping, social support, anger expression and non-cancer stressors, by cancer type

 
Cancer-specific social support and network. Cancer-specific social network was evaluated as number of persons in each source of support. The SFSS functional subscales were established according to the sources of support [31Go, 32Go] as the amount of support received from each source. These were reasonably homogeneous (Table 2). The highest amount of support was received from the spouse or partner and, rather unexpectedly, from physicians and nurses. Acquaintances were the only source that was clearly less supportive than the remaining sources. Breast cancer patients received more support than melanoma patients. Differences between the groups investigated are presented in Table 3. Gender differences (melanoma) were minimal. When the differences in support were tested between the treatment groups (melanoma and breast cancer patients together, categorized as surgery only versus surgery plus adjuvant treatments), patients undergoing surgery only reported less support from several sources. Older patients received less support than younger ones.


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Table 3. Differences in cancer-specific social network, social support and coping with cancer, by cancer type, treatment and gender

 
Anger expression related to type C personality. Anger expression traits were identified as anger-in, anger-out and anger control (Table 2). The anger control trait predominated over the anger-in and anger-out traits. There were no statistically significant differences between the two cancer types or genders.

Non-cancer stress. The patients reported a mean of 2.5 non-cancer life events during the previous 12 months (Table 2). There were no differences between the two cancer types. Older melanoma patients had fewer life events than younger patients (P values < 0.001 and <0.05). Women experienced more life events in general (mean 3.5 versus 1.9; P=0.008) and more negative events than men (mean 3 versus 1.9; P=0.011). The most frequently mentioned events were ‘serious illness or injury of a close family member’, ‘a major change in sleeping habits’ and ‘death of a family member’ (each by 20% of the patients), followed by ‘a major change in financial status’, ‘in social activities’ or ‘in eating habits’, and ‘changed work situation’.

The patients reported a mean of two chronic strains in their lives (Table 2). The most common strains experienced were ‘burdensome work facilities or circumstances’, ‘own chronic illness’ (diagnosed over 1 year previous) and ‘chronic illness of a family member’, the first two being experienced by more than one-third of the patients.

Components of QoL
Psychological and physical symptoms. Only 2% of the patients reported no symptoms at all according to the RSCL (Table 4Table 4). The symptoms were divided into two separate subscales: psychological and physical. There were no differences in the amounts of psychological or physical symptoms between cancer type or between treatment modalities of breast cancer. Female melanoma patients reported psychological symptoms more often than males (mean 7.26 versus 4.34; P=0.009). The younger the melanoma patients, the more likely they had psychological symptoms (r=–0.40, P=0.001) and depression (r=–0.24, P <0.05).


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Table 4A. Amounts of reported symptoms, by cancer type

 

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Table 4B. Most common symptoms (psychological + physical) by RSCL

 
Perceived QoL. Perceived QoL (self-reported ascending scale from 1 to 7) had a mean between quite good (5) and good (6) (Table 4Table 4). No patient felt their life quality to be very poor (1), although one breast cancer patient perceived it to be poor (2). There were no disease, gender or treatment differences in this measure.

Depression. The DEPS scale had excellent homogeneity in the samples and was normally distributed (Table 4Table 4). The most common depressive symptoms were present in two-thirds of the patients: ‘felt blue’ (72%), ‘felt low in energy or slowed down’ (67%) and ‘felt everything was an effort’ (62%). In the average score mean, there were no differences between the two cancers or treatment modalities in breast cancer. Female melanoma patients reported depression more often than males (mean 7.03 versus 4.19; P=0.009).

Breast cancer-specific symptoms. Every breast cancer patient had at least some symptoms mentioned in the EORTC QLQ-Br23. Over 90% of the patients still had symptoms in the breast area (Table 4Table 4). One-third of the patients reported that breast cancer had not affected their self-perceived body image, with only 6% of the patients scoring above the scale mean. About 60% of the patients reported that they were sexually active. The most common and most frequently experienced symptom in the QLQ-Br23 was ‘worrying about future health’, which was experienced by 79% of the patients. The next most frequently experienced symptom was ‘hot flushes’ (56%), followed by several symptoms in the treated breast area. Patients receiving adjuvant treatments naturally had more symptoms in the breast area than the other patients (P<0.001).

Associations between symptoms. All symptom measures correlated (r) highly, with P-values <0.001. The number of psychological symptoms was strongly correlated with physical symptoms, and depressive symptoms correlated with all other symptoms. The 1-item perceived QoL measure was highly negatively correlated with the amount of symptoms. Only symptoms in the breast area (by QLQ-Br23) were separate, although they were associated slightly positively with physical symptoms.

Factors predicting QoL
The main predictors of QoL were evaluated with regression analysis. The dependent variables included the components of QoL one by one. The independent variables included factors in the psychological stress processes, age, gender, mode of cancer treatment, type of surgery in breast cancer (conserving surgery/mastectomy), working status and family income. The only male breast cancer patient and patients with distant metastases were excluded from the multivariate analyses. In regression models, first, only factors in the cancer-specific stress processes were included (not shown), and then also the non-cancer stress variables (Table 5A). The treatment mode appeared to have some distinguishing effect (Table 3). Therefore, models were also created separately for the adjuvant treatment group (Table 5B).


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Table 5A. Predictors of QoL in regression analysis, by diagnosis

 

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Table 5B. Predictors of QoL in regression analysis in patients with adjuvant treatment

 
According to the model (Figure 1), factors in the stress process predict QoL outcomes, and our results supported this. The strongest predictors were the psychosocial factors, not cancer type or treatment. Of the cancer-specific stress processes, the effect of behavioral escape-avoidance coping was the most important predictor of additional symptoms and poorer well-being. The effect of the non-cancer stress variables (Table 5A) on outcomes was additional and strong. The included factors accounted for 19–57% of the variance (cumulative r2) of the general QoL scores: the predicting power of the measured variables was strong, accounting for almost half of the total variance (Table 5A and B), depressive symptoms being the best explained (total r2) QoL outcome. Regarding the breast cancer-specific symptoms (Table 5A), the measured factors had less predicting power (r2 0.17 and 0.25) than in the general QoL, and non-cancer stress was not a statistically significant predictor. Patients on adjuvant cancer treatment had more breast area symptoms than those undergoing surgery only, and feminine body-image was poorer in those who had undergone mastectomy.

The non-cancer stress variables (number of negative events and burden of chronic strain) and the escape-avoidance coping were the most important factors predicting poorer outcome (Table 5A and B). The social structure (network) variables ‘number of household members’ in melanoma and ‘number of involved physicians’ in breast cancer predicted poorer perceived QoL. In breast cancer, anger-in trait predicted more psychological and depressive symptoms. Also, seeking social support coping seemed to be associated with increased psychological symptoms. With regard to somatic complaints, focusing on the positive coping in melanoma predicted more reported symptoms. Factors that predicted better QoL (protective factors) included being in working life, minimization of the impact of cancer, the coping pattern focusing on positive in breast cancer, the coping pattern distancing, positive life events, and social support from family, relatives, acquaintances and other patients. Minimization, distancing and most influences of support emerged only in patients receiving adjuvant treatments (Table 5B).


    Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Appendix 1. Items included...
 References
 
The psychometric properties of the measures were sufficient or good, and a broad spectrum of factors involved in the psychological stress processes was evaluated. The measurement was undertaken using quantitative, validated self-report scales: the patients' own experiences were searched as recommended by Osoba [10Go] in oncological QoL research. The results mainly supported the study hypotheses (Figure 1) formulated based on the literature. Although the structure of coping did not correspond with what has been presented by Folkman and Lazarus [17Go, 30Go], we identified the same five patterns of coping with cancer as Dunkel-Schetter et al. [37Go] and Stanton and Snider [36Go] in their cancer samples. Cancer-specific social support was distinguished according to the sources of support [32Go]. The symptom measures indicating QoL were not used as diagnostic psychiatric tools, but were developed to obtain distributions of the domains in populations [1Go]. The main QoL measure, the RSCL, is cancer-specific and evaluates the numbers of psychological and physical symptoms experienced by the patients [29Go]. The widely used European QoL measure, the EORTC QLQ-30, was not available in Finland when the present study was initiated; only the breast cancer module (Br23) [35Go] of it was available and included here.

Because of the large amount of previous research in the area, we were able to derive hypotheses concerning the factors and their relationships within the psychological stress processes in cancer. On the basis of these hypotheses, a model of psychosocial factors was constructed, statements on the dependencies and their directions made, and regression analysis used to test these dependencies further. In the present non-experimental cross-sectional design, the regression analyses do not allow statements about causality between the factors, but do allow interpretation of the direction of dependence [38Go, 39Go]. It should be noted that the directions of dependencies were investigated according to the study hypotheses only.

Melanoma and breast cancer were chosen for the study because they are very different diseases, and their postsurgical treatments differ. It was hypothesized that there may also be differences in psychological stress processes, e.g. in the coping patterns used or in the QoL experienced by the patients. Unexpectedly, there were only minor differences in these between melanoma and breast cancer. Within the breast cancer group, there were no differences according to the treatment modality: surgery only versus surgery plus adjuvant treatments.

The measured factors in the psychological stress processes were important predictors of QoL: they explaining as much as one-third or nearly half of the variance in the symptoms. Several types of psychological factors predict QoL and mood of the patients, consistent with the findings of Stanton and Snider [36Go] and the theory of Lazarus and Folkman [15Go–17Go]. When only those factors concerning cancer-specific stress processes were investigated, the most influential factor was behavioral escape-avoidance coping (see Appendix 1), which strongly predicted poorer QoL. When non-cancer stress was included in the model, the most influential variables concerned non-cancer life stresses. The two escape-avoidance coping patterns and non-cancer life stress predicted increased number of symptoms and poorer well-being in terms of all measures of QoL.

Of the sociodemographic and socioeconomic variables, only working status had influence: being in working life was associated with better QoL.

The escape-avoidance coping patterns appear to be harmful in QoL, as reported previously [8Go]. In particular, behavioral escape-avoidance coping strongly predicted worse psychological well-being. In addition, it was the only coping pattern that was not applied by all patients: some patients did not apply it at all and were thus free from its deteriorating effect. Paradoxically, seeking social support coping was associated with more psychological symptoms. The only QoL-enhancing coping pattern was distancing, but it emerged only in patients undergoing adjuvant treatment. It included items describing systematic planning, calmness and ‘looking for the silver lining’. The focusing on the positive pattern appeared to have increased overall QoL in breast cancer, but decreased physical QoL in melanoma. Like working status and seeking social support, it may not have been the cause of the symptoms but rather an associating factor that occured simultaneously or even as result of the existence of symptoms.

Of the anger expression personality factor, the hypothetical cancer-prone anger-in trait predicted an increased amount of psychological symptoms, but quite weakly, and only in breast cancer.

Breast cancer-specific symptoms were not as strongly associated with factors in the stress processes as the other QoL domains. In these, heavier cancer treatment was, naturally, a strong predictor of symptoms. However, behavioral escape-avoidance coping also predicted problems in body image, and social support seemed to enhance recovery from breast cancer treatments.

In general, non-cancer life stresses appear to be important factors in the QoL of newly diagnosed cancer patients. To obtain comprehensive pictures of those situations in which the individual patients have to cope with their cancer, it may be beneficial to screen for non-cancer life stresses.

Social support was the only major distinguishing factor in the sample, the division occurring between melanoma and breast cancer. A simple t-test comparison between treatment modality groups within the total sample indicated a possible support-increasing effect of adjuvant cancer treatment. Although this difference was not obtained between treatment mode groups in breast cancer, adjuvant treatment received by >70% of the breast patients may have been related to this increased support. Separate regression models were created for the adjuvant treatment group only. The harmful effects of non-cancer stress remained in the models. However, patients receiving adjuvant medical treatments had more QoL-enhancing factors. Psychological well-being was enhanced by minimization of cancer diagnosis (less negative impact), which has previously been reported to enhance survival time [40Go]. The beneficial factors included also social support received from family, relatives, acquaintances and other patients. Each predicted better QoL, but explained only a small percentage of the total variance and emerged in different QoL outcomes.

In general, social support appeared to be a health-enhancing factor, as previously demonstrated [19Go, 23Go, 41Go, 42Go]. The support received from people in the same situation enhanced psychological well-being of the patients undergoing adjuvant treatment. However, the direction of dependence is controversial; the ability to recruit support from acquaintances may be seen as a sign of a person who is not depressed and support from family may be considered as a part of QoL. It was interesting that support from relatives seemed to slightly protect breast cancer patients from symptoms in the treated breast area. It should be noted that the experience of support is formatted in the interaction between the patient and the relationships that act as sources of support [19Go]. Thus, support is also a question of patients' resources: those who are socially skilled may see their interactions as being more supportive.

It was a disadvantage of this study that the sample subgroups were relatively small. In breast cancer, there may have been too few patients in the treatment subgroups for statistical comparison, and thus treatment differences did not emerge within breast cancer. The numbers of male patients should have been higher for more reliable gender comparison, and it was a disadvantage that all the men had the same cancer (melanoma) and all patients receiving adjuvant treatment were women. The present data were restricted to the first few months following diagnosis; thus there was no information on the further course of the stress processes. Interactions between the independent variables were not tested here, but analyses not shown here revealed that the predictors were the same. The study is continuing and the same patients have been followed up using the same procedure for 8 years after the first interview.

In agreement with the model by Dolbeaut et al. [2Go], differences in QoL were explained by the mediating psychosocial variables, not directly by the independent variables such as type of cancer (melanoma or breast cancer) or treatment modality. Distress had previously been reported to be independent of the stage of cancer [8Go]. The factors in the psychological stress processes were the most effective predictors, and seemed to mediate between the impact of cancer and its treatment in the QoL of a patient. The fact that QoL was predicted differently in the adjuvant treatment group concurs with the model and indicates the independent nature of the treatment. The only psychological factor that differed between the cancer treatment groups, the amount of cancer-specific social support received, was higher when there was more intensive cancer treatment. This may have been the reason for the differences observed between the treatment groups in predictors of QoL: social support induced by medical cancer treatment may have changed the processes.

If adjuvant medical cancer treatment has the additional effect of resulting in more social support, which in turn affects the psychological stress processes and QoL, those patients not undergoing these treatments also receive something less in the psychosocial sense. Social support has generally been reported to be the means to changing psychological stress processes, especially coping, and their outcomes [2Go, 23Go, 28Go, 41Go, 42Go]. Confusingly, aggressive adjuvant cancer treatment has been reported to result in improved QoL [10Go]. The present findings may offer an explanation for this: in adjuvant treatment QoL may be increased by higher amounts of cancer-specific social support, which is associated with the medical treatment procedures. If comprehensive cancer care or psychosocial interventions contain deliberately induced increases in the amount of social support received, it may, with this type of process, lead to better QoL in patients.


    Appendix 1. Items included in the coping pattern ‘Behavioral escape-avoidance’
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Appendix 1. Items included...
 References
 
The items included in the coping pattern behavioral escape-avoidance were:

I took it out on other people;  I generally avoided being with people;
I took a big chance or did something very risky to solve the problem;
I kept others from knowing how bad things were;
I realized that I had brought the problem on myself;
I tried to make myself feel better by eating, drinking, smoking, or using drugs or medications;
I expressed anger to the person(s) who caused the problem;
I tried not to burn my bridges, but left things open somewhat.


    Acknowledgements
 
The Medical Research Fund of Tampere University Hospital, the Finnish Cancer Foundation, and the Pirkanmaa Regional Fund of the Finnish Cultural Foundation financially supported this project.

Received for publication April 24, 2003. Revision received September 17, 2004. Revision received April 23, 2004. Accepted for publication December 10, 2004.


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Appendix 1. Items included...
 References
 
1. McDowell I, Newell C. Measuring Health. A Guide to Rating Scales and Questionnaires, 2nd edition. New York: Oxford University Press 1996.

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