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cancer Intervention

cancer Intervention - D 1 UNIVERSITY OF Antoni M H Lehman J...

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Unformatted text preview: D 1 UNIVERSITY OF Antoni, M. H., Lehman, J. M., Kilbourn, K. M., Boyers, A. E., Culver, J. L., Alferi, S. M., Yount, S. E., McGregor,-B. A., Arena, P. L., Harris, S. D., Price, A. A., & Carver, C. S. (2001). Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early—stage breast cancer. Health Psychology, E, 20— 32. Copyright 2001 by the American Psychological Association, Inc. This article has been copied and delivered electronically by permission. No further copying or distribution is permitted without permission of the publisher. Department of Psychology PO. Box 248185 Coral Gables, FL 55124-2070 Telephone (505) 284-2814 Fax (505) 284-3402 Health Psychology 2001, Vol. 20. No. 1. 204?. Copyright 2001 by the American Psychological Association. Inc. t)278—6l$3/01/$5.00 D01: 10.lt)37/l0278-6l33.20.1.20 Cognitive—Behavioral Stress Management Intervention Decreases the Prevalence of Depression and Enhances Benefit Finding Among Women Under Treatment for Early-Stage Breast Cancer Michael H. Antoni, Jessica M. Lehman, Kristin M. Kilboum, Amy E. Boyers, Jenifer L. Culver, Susan M. Alferi, Susan E. Yount, Bonnie A. McGregor, Patricia L. Arena, Suzanne D. Harris, Alicia A. Price, and Charles S. Carver University of Miami The authors tested effects of a 10-week group cognitive—behavioral stress management intervention among 100 women newly treated for Stage 0—11 breast cancer. The intervention reduced prevalence of moderate depression (which remained relatively stable in the control condition) but did not affect other measures of emotional distress. The intervention also increased participants’ reports that having breast cancer had made positive contributions to their lives, and it increased generalized optimism. Both remained significantly elevated at a 3-month follow—up of the intervention. Further analysis revealed that the intervention had its greatest impact on these 2 variables among women who were lowest in optimism at baseline, Discussion centers on the importance of examining positive responses to traumatic events— growth. appreciation of life, shift in priorities, and positive affectvas well as negative responses. Key words: stress management, benefit finding. depression. breast cancer Approximately 175,000 women in the United States were diag‘ nosed with breast cancer in 1999 (American Cancer Society, 1999). Breast cancer patients confront a variety of stressors, in- cluding the diagnosis itself (Andrykowski, Cordova, Studts, & Miller, 1998; Glanz & Lerman, 1992; Stanton & Snider, 1993); intrusive medical procedures and aversive side effects of treatment (Gottschalk & Hoigaard, 1986; Hann, Jacobsen, Martin, Azzarello, & Greenberg, 1998; Jacobson, Bovbjerg, & Redd, 1993; Jacobsen et al., 1995; Kaplan. 1994; Longman, Braden, & Mishel, 1996); and a variety of personal. psychological, and physical losses (Carver et al., 1998; Deadman, Dewey, Owens, Leinster, & Slade, 1989; Schag et al., 1993; Spiegel, 1996). The impact of this experience has changed over the years for many women, however. Improvement in medical procedures and changes in the psychological climate surrounding the disease have both helped to blunt the impact of cancer and its treatment. Michael H. Antoni, Jessica M. Lehman, Kristin M. Kilbourn, Amy E. Boyers, Jenifer L. Culver. Susan M. Alferi, Susan E. Yount. Bonnie A. McGregor. Patricia L. Arena, Suzanne D. Harris, Alicia A. Price. and Charles S. Carver, Department of Psychology, University of Miami. This project was supported by a research grant from the National Cancer Institute (CA-64710) and a training grant from the Department of Defense (J4236-DAMD1794). We are grateful to Robert P. Derhagopian, Alan S. Livingstone, Frederick L. Moffat Jr., Jodeen E. Boggs, Sharlene Weiss, and the Dade County American Cancer Society for their help in recruiting participants, and to Sheri L. Johnson for statistical help. We are also deeply grateful to the participants themselves, for sharing their time and experi- ences with us. Correspondence concerning this article should be addressed to Michael H. Antoni, Department of Psychology. University of Miami, Coral Gables, Florida 33124-2070. Electronic mail may be sent to [email protected] Research in the last 10 years has found that, in the absence of prior history of psychiatric disturbance, among early—stage breast cancer patients (i.e., Stage I or Stage II, which have good prognoses). severe psychiatric symptoms are relatively rare and far less com- mon than among patients with more advanced cancers (Andersen, Anderson, & deProsse, 1989: Bloom et al., 1987; Carver et al., 1993; Ganz. Rowland, Desmond, Meyerowitz, & Wyatt, 1998; Gordon et al., 1980; Lansky et al., 1985; Penman et al., 1987; for reviews see Glanz & Lerman, 1992; Irvine, Brown, Crooks, Rob- erts, & Browne, 1991; Meyer & Salovey, 1996). The experience of early-stage breast cancer is now widely seen as a crisis in the woman’s life that has many diverse ramifications (Spencer et al., 1999) but that is weathered successfully by the majority of patients during the period of about 1 year postsurgery (Andersen et al., 1989). Positive Consequences Although diagnosis of and treatment for cancer are distressing and disruptive, there is an increasing awareness in both research and clinical communities that the cancer experience often has sequelae that patients view as positive or beneficial. A substantial number of patients report experiences such as improvement in personal resources and skills, an enhanced sense of purpose, en- hanced spirituality, closer relationships with significant others, and changes in life priorities (e.g., Andrykowski, Brady, & Hunt, 1993; Collins, Taylor, & Skokan, I990; Curbow, Legrow, Baker, Win- gard, & Somerfield, 1993; Dow, Ferrell, Leigh, Ly. & Gulasek- aram, 1996; Ferrell, Dow, Leigh, Ly. & Gulasekaram, 1995; Ferrell, Grant. Funk, Otis-Green, & Garcia. 1997: Fromm, An- drykowski, & Hunt. 1996; Kahn & Stcevcs, 1993; Kurtz, Wyatt, & Kurtz, 1995; Snodgrass, 1998). As paradoxical as it seems, some cancer patients say that being diagnosed with cancer has been a N I BENEFIT FINDING IN CANCER 21 positive experience in their lives (Thornton, 1999, reviewed this literature in detail). Such findings among cancer patientsjoin a diffuse but growing literature in other areas suggesting that traumatic events can yield positive outcomes (e.g., Affleck & Tennen, 1996; Aldwin, Sutton. & Lachman, 1996; Davis, Nolen-Hoeksema, & Larson, 1998; Ebersole & Flores, 1989: Folkman, 1997; Ickovics & Park, 1998: Lehman et al., 1993; McMillcn, Smith, & Fisher. 1997: McMillen, Zuravin, & Rideout, 1995; Mohr et al., 1999; O’Leary & lckovics, 1995; Park, Cohen, & March, 1996; Schaefer & Moos, 1992; Tcdeschi & Calhoun, 1995, 1996; Tedeschi. Park, & Calhoun. 1998; Thompson, 1985; Updegraff & Taylor, in press). The events studied have varied widely, including bereavement, infertility, childhood sexual abuse. tornadoes, mass killings, and plane crashes. The perception of benefit does not appear to stem primar- ily from the passage of time since the event occurred—it some— times occurs quite early (Burt & Katz, 1987; Fromm et a1., 1996; McMillen et £11., 1997). Neither does it reflect simply an absence of distress (Fromm et a1., 1996; Park et at, 1996; Ryff. 1989)— indeed, there is even some suggestion that event severity can relate positively to positive sequelae, as though severe events offer the most potential for growth (McMillen ct 211., 1997). On the other hand, there is some evidence that finding benefit in trauma may reduce later distress (McMillen et al., 1997). It seems to permit resolution of the experience, allowing the person to move onward with life (cf. Carver & Scheier, 1998; Folkman, 1997; Janoff— Bulman, 1992; Scheier & Carver, in press; Taylor, 1983). . Tedeschi and Calhoun (1995; Calhoun & Tedeschi, 1998, 1999), who have studied the experience of growth after trauma in some detail, suggest that clinical intervention can help foster such growth—that is, in their view, an intervention can take advantage of the trauma-induced disruption in the person's life to foster a new organization of the self that is better than the pre-existing one. This possibility is intriguing, but we are unaware of any research that has addressed it empirically. Doing so was one purpose of the study reported here. Most current interventions with cancer patients (Andersen, 1992; Trijsburg, van Knippenberg, & Rijpma, 1992) use a com— bination of cognitiveibehavioral stress management (CBSM) techniques. 0f the studies reviewed by Trijsburg et al. (1992). almost all had reduction of stress and distress as the primary goal. Other goals included increasing effective coping strategies (11 of 22 studies); expression of concerns and feelings (10); preserving social support (9); debunking myths about the illness (8); promot— ing hope, positive self—image. and adequate sexual relations (5); and encouraging relaxation (5). In the study reported here we examined the influence of a CBSM intervention with the goals just outlined, in a sample of early—stage breast cancer patients. The intervention was designed to teach behavioral and cognitive strategies in a supportive group setting and to give women the opportunity to role play the strat— egies. The intervention had not been designed specifically to enhance benefit finding; however, it appeared to us that it might well yield such an effect as well as ameliorate negative reactions. For that reason we included a measure of benefit finding in the study as well as measures of emotional upset. The women were recruited into the project shortly after surgery and were random— ized to either the psychosocial intervention or to a more limited control experience. We followed patients throughout the first year after their cancer diagnosis and treatment. We assessed the impact of the intervention on several outcomes: distress (mood disturbance. depressive symptoms, and thought intrusion and avoidance), perceptions of benefit from having breast cancer, and generalized optimism about the future. We also in- cluded a measure of emotional processing, to test whether en- hanced emotional processing is a mechanism for the intervention‘s benefits. Finally, we examined a potential moderating role for dispositional Optimism. We predicted that women initially lower in optimism, being in the greatest need, would benefit most from the intervention. We note, however, that an alternative hypothesis might be posed: that women high in optimism, being most open to the possibility of gain, would benefit most from the intervention. Method Participants Participants were early—stage breast cancer patients recruited from sev- eral hospitals and medical practices in the Miami, Florida, area. In most cases, they responded to a letter from their physicians soliciting their participation. Others were recruited through flyers placed in offices and distributed by the American Cancer Society. In all cases the study was described as a project on the effects of stress management training on the experiences of women undergoing treatment for breast cancer. Interested women called the project’s phone number and spoke with a (female) researcher who screened them for eligibility. Information regarding staging and date of surgery was obtained in this phone screen. Of the women contacted by letter, approximately 80% called for more information: of those who called. 98.6% of those who met inclusion criteria participated in the first assessment. Criteria for inclusion were ( a) breast cancer diagnosed at Stage II or below and (b) surgery within the last 8 weeks. Potential participants were excluded if they reported a prior cancer (7), prior psy— chiatric treatment for serious disorder (hospitaliLation or fonnal diagnosis of psychosis. major depressive episode. panic attacks. suicidality, or sub- stance dependence—S), major concurrent disease (4), or lack of fluency in English (1). The effects of the intervention were studied over an extended period of time. The sample discussed here consists of the 100 women who completed initial assessments, postintervention assessments, a 3—month postinterven- tion follow-up, and a 9—month postintervention follow-up. A total of 136 women completed the initial assessment. Attrition was as follows: Eleven dropped out by the postintervention assessment (8.1%): 9 more (6.6% of the starting sample) failed to complete the 3—month follow-up; and 16 more (11.8% of the starting sample) failed to complete the final 9-month follow- up. Attrition did not differ by condition at any of these intervals. Comparisons between women who did and did not leave the study yielded no difference in regard to stage. number of positive nodes. surgical procedure, age, ethnicity, marital status, or presence versus absence of chemotherapy or radiation (all ps > .2, except ethnicity, which had [7 > .08). Those who left before posttreatment did not differ from those who stayed on any initial variable (optimism, distress, depression, avoidance, intrusion, or positive contributions, all ps > .3). Those who left between posttreatment and 3-month follow-up did not differ on any posttreatment variable from those who stayed (all ps except one > .3: Center for Epidenriologic Studies—Depression scale [CES—D: Radloff, 1977] p = .09, tending to be higher among those who did not continue), Those who completed the 9emonth follow-up did not differ from those who dropped out on any of the variables described above at baseline or on any index of distress or the measure of positive contributions at posttreatment or the 3—month follow-up tall ps > ,5). Diagnoses of the 100 women who completed all assessments were Stage 0 (ti = 10), Stage 1 (n = 48), or Stage 11 (n = 41). Nodal involvement 22 ANTON] ET AL. ranged from 0 to 24 (M = 1.34. SD = 4.34). Forty~eight ofthe women had lumpectomies, 40 had mastectomies, 11 had bilateral mastectomies, and 1 had a bilateral lumpectomy; 42 of the women were subsequently treated with chemotherapy, 47 were treated with radiation (19 of these received both chemotherapy and radiation), and 47 received tamoxifen. The mean age was 50.23 years (SD = 9.15, range = 29—79). Patticipants included 74 non-Hispanic Whites, 16 Hispanics, 6 Blacks, and 4 self—identified as "other." Seventy/five of the women were married or in an equivalent relationship. 13 were divorced or separated, 3 were widowed, and 9 were single. Fortyeone responded affirmatively to the question “To the best of your knowledge, do you have a family history of breast cancer?" The average amount of education was 15.21 years (SD = 2.20). Eighty-two women were currently employed. and 18 were not currently working outside the home. Procedure Participants completed an initial assessment by mail 4—8 weeks after their surgery date. After this, participants were randomly assigned to the intervention or control condition. The intervention took place over a 10-week period following the initial assessment. Women assigned to the intervention (n — 47) participated in a CBSM intervention (described below) beginning 6—8 weeks after surgery. The women were reassessed shortly after the conclusion of the intervention (which was 3 months after the initial assessment), again after a 3-month follow-up, and again after a 9-month follow-up (which was a total of 14 months after surgery). Women assigned to the control condition (21 = 53) were invited to participate in a 1-day seminar approximately 16—18 weeks postsurgcry, a time that was after completion of the second assessment (which, as in the case of the intervention group, was 3 months after the initial assessment). Similar to the intervention group, women in the control group were then assessed again after a 3-month follow-up, and again after a 9-month follow-up. Participants in both conditions met in groups of up to 8 in a large room within the Psychological Services center at the University of Miami came pus or in a similar room on the University of Miami medical campus. Each room was equipped with flat couches used exclusively for progressive muscle relaxation (PMR) exercises. Both the intervention and the 1—day seminar were co-led by postdoctoral fellows and advanced graduate stu- dents in clinical psychology who had been trained in the intervention and seminar protocols. All were female, and each rotated between intervention and control cohorts. Assessments were handled by graduate students who were not conduct- ing the intervention with that cohort. Although the timing of the assess- ments was tied to the time of surgery rather than to other medical events, such as adjuvant therapy, each assessment included measures of such medical events. Intervention. The intervention was a closed, structured group intervenv tion (Antoni, in press), which met weekly for ten 2-hr sessions (cf, Antoni et al., 1991: Lutgendorf et al., 1997) and used CBSM techniques inter- woven with didactics. It included in-session didactic material and experi- ential exercises and out-of-session assignments (practicing relaxation ex- ercises and monitoring stress responses). The intervention focused on learning to cope better with daily stressors of cancer- and treatment—related problems and issues and optimizing one’s use of social resources. The intervention used group members and group leaders as role models (for positive social comparisons and social support); encouraged emotional expression: replaced doubt appraisals with a sense of confidence by means of cognitive restructuring (Beck & Emery, 1985); and honed skills in anxiety reduction (by PMR and relaxing imagery, Bernstein & Borkovec. 1973), interpersonal conflict resolution, and emotional expression (by means of assertion training: Fensterheim & Baer, 1975). The CBSM package thus included both problem-focused (e.g., active coping and planning) and emotion-focused (e.g., relaxation training, use of emotional suPport) coping strategies. Attendance at the 10 group meetings averaged 8.65 (SD = 1.44, Mdn = 9, range: 5—10). Reports were also collected on the incidence of relaxation practice outside group meetings (although this request received only partial compliance). Of the 39 women who reported on this variable for 6 or more weeks, the average rate of weekly practice reported was 6.03 (SD = 3.24). Control-group .reminar. Rather than using a no-treatment control group, we used a procedure in which participants received a condensed version of the information provided in the full—scale intervention. Women in this condition attended a daylong seminar (56 hr) during which they received information about the nature and effects of stress reactions: an outline of the cognitive appraisal process and how it relates to stress and emotional states: practice on various relaxation training exercises; and exercises for changing self-defeating cognitive appraisals, reducing ten» sion. and acquiring adaptive coping strategies. This session was designed to provide at least some information on all topics covered in the CBSM condition. However, it lacked the therapeutic group environment and accompanying emotional support: the opportunity to hear about other group members” weekly frustrations and triumphs in dealing with their situation: the opportunity to role play the techniques and receive group feedback; and the opportunity to observe other group mem- bers model new appraisals, relaxation techniques. and coping strategies. Obviously. the presentation of all materials was also much more condensed than in the intervention groups. This type of control has at least two benefits compared to no-treatment control or wait-list control grou...
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