Negative affectivity, restriction of emotions, and site of metastases predict mortality in recurrent breast cancer

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Abstract

Objective: To assess whether negative affectivity and restriction of emotions predict survival time with recurrent breast cancer.

Methods: Thirty-two patients with recurrent breast cancer, diagnosed 6–19 months earlier and stabilized using surgical, medical and/or radiation therapies, were enrolled. Cox regression survival analyses, including initial severity of metastases (RR=4.3 [1.3–14.3]; p=0.02), were used to explore the association of psychological variables with survival.

Results: Low chronic anxiety in the context of low emotional constraint predicted low mortality (RR 0.07 [0.01–0.52]; p=0.007). However, patients with low chronic anxiety scores but with high constraint had higher mortality (RR=3.7 [1.2–11.5; p=0.02). High chronic anxiety, with or without high constraint, also predicted earlier death, as did high control of feelings.

Conclusion: An integrated model of negative affectivity in the context of restriction of emotions appears to strengthen the prediction of survival based on severity of breast cancer metastases.

Introduction

Prospective, observational studies have suggested that a woman's negative affectivity and restriction of emotion can predict her survival time with breast cancer [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. Methodological limitations account for some of the inconsistency in the results of these studies [14], yet the findings are sufficiently robust to warrant further investigation [15], [16].

Research suggests that measures of negative affectivity are not reliable predictors of survival because people who claim to experience low negativity are not one concordant group. Their negative affectivity may be either (a) very low or (b) unexpressed. Our research seeks to clarify the predictive value of negative affectivity by adding measures of restriction of emotions to a study of recurrent breast cancer progression. This allows us to correctly distinguish patients who report low negativity and who are truly low in distress vs. those who are restricting their strong negative feelings.

The study described here focuses on two processes through which restriction is used to regulate emotions. The first is emotional constraint, in which stoicism and emotional self-control become incorporated in the patient's view of herself. This reduces awareness of emotional reactions, is often accompanied by little or no acknowledgment of negative affectivity, and often operates as an involuntary process for regulating emotions [17]. In 1984, Watson et al. [18] reported that emotional constraint in breast cancer patients is accompanied by chronic physiologic arousal, which may mediate the effect of emotional constraint on survival. A second process for restricting emotions is voluntary control of feelings, by which patients attempt to change or control their acknowledged emotions rather than accept them as they are. It is important to differentiate patients with these two ways of restricting emotions because they may benefit from different psychosocial interventions [19], [20].

The following review of the literature on negative affectivity and restriction of emotion as predictors of breast cancer progression separates research on newly diagnosed disease from studies of recurrent disease. This is important because the relationship of psychosocial variables to disease progression may vary with the stage of disease being studied.

Lack of attention to the time in the disease course when assessments are done has made interpretation of previous studies difficult. Acute distress related to the diagnosis or progression of breast cancer is likely to resolve, whereas patients who are chronically anxious are more likely to remain distressed. Emotional distress is also likely to rise during the terminal phase of the illness [15]. General health research has shown that chronic anxiety is more deleterious than transient negative affectivity [16]. Whether this is the case with breast cancer, however, has not been established.

Ideally, multiple psychosocial assessments would be conducted in large prospective studies of psychosocial predictors of disease progression, and the timing of these would be based on a theory of how the expected changes relate to the outcomes of the study. Multiple assessments were not possible in our study, so the collection and interpretation of data were done with deliberate care to assess psychological status beginning at least 6 months after recurrence and prior to the known terminal phase in order to detect the baseline functioning of the individual after the acute adjustment to breast cancer recurrence had occurred and before the effects of terminal illness.

Negative affectivity has not been shown to predict disease progression in the majority of studies of newly diagnosed breast cancer patients. Levy (n=90) found that a higher Total Distress score on the Profile of Moods States predicted shorter time from diagnosis to recurrence among those who recurred, but it did not predict whether breast cancer recurred [1]. Gilbar (n=40) found higher emotional distress to predict shortened survival time, but biomedical variables were not included in the analyses [13]. Four other prospective, longitudinal studies which involved 593 newly diagnosed breast cancer patients did not find negative affectivity to be a significant predictor of disease progression after controlling for biomedical risk factors [5], [6], [7], [8].

There is more support for the hypothesis that restriction of emotion in newly diagnosed breast cancer patients predicts poor outcome. Greer [12] labeled it stoic acceptance coping and found it to predict decreased survival in newly diagnosed breast cancer patients. Levine et al. [8] reported a “coping style” which restricts emotions to be predictive of breast cancer recurrence. Buddeburg, however, examined self-encouragement/distraction coping style and found no association with disease progression. We found no data on the correlation of these measures of restriction of emotion, however, so comparing results across studies may not be valid.

Some studies suggest that expression (rather than restriction) of emotion predicts improved breast cancer outcome [11], [12], even though negative affect may be high [17]. Dean and Surtees [3] (n=122) studied major depressive disorder, which is unlikely with high restriction of emotion [17]. When it was identified at the time of surgery for newly diagnosed breast cancer, major depressive disorder predicted longer time to recurrence and increased survival [3]. In contrast, assessment of depression in the same sample 3 months after surgery did not predict recurrence or survival. These results suggest that expression of distress, as an acute response to breast cancer surgery, is health-inducing, whereas the negative effects of prolonged negative affectivity may neutralize the benefits of affective expression. This is consistent with the findings of Barraclough et al. [4] that depressive disorder, detected later in the disease course, did not predict time to recurrence.

There are only four studies involving 147 recurrent breast cancer patients in which negative affectivity has been investigated as a predictor of survival. Studies by Jensen [11] and Derogatis et al. [9] showed that measuring restriction of emotions, with its unfavorable effects, helps to clarify the deleterious effect of negative affectivity on survival. Levy et al. [2] also found negative affectivity associated with early mortality, but Jamison et al. [10] did not. Selection bias and an arbitrary distinction of 16 months as long-term survival limit the latter study.

Disease severity has not been adequately accounted for in these studies. Site of metastases, disease free interval, estrogen receptor negativity, evidence of cancer in axillary lymph nodes, and tumor grade have all been reported as prognostic indicators, but only a few studies have attempted to weigh them according to their relative strength of influence [21]. Menopausal status may change such relative influence, as well. Our study was designed to include these variables.

Section snippets

Study design

The study reported here was designed to carefully account for differences in disease severity and to clarify the joint effects of negative affectivity and restriction of emotions on survival after recurrent breast cancer. The specific questions to be answered using survival analyses were as follows:

  • 1.

    Do separate measures of negative affectivity and restriction of emotion predict survival time after recurrent breast cancer when analyzed in conjunction with disease severity?

  • 2.

    If (1) is true, what

Participants

A consecutive sample of breast cancer patients who were receiving treatment in four academic medical centers in the Washington, DC, area for recurrent breast cancer was identified. Only subjects in the local area with no functional impairment were eligible. These data are part of a study of psychological risk factors for breast cancer progression, in which the influence of family and social relationships on individual patient risk factors and on disease outcome was examined. The research

Patient and disease characteristics

The mean time interval from diagnosis of recurrent breast cancer to research assessment was 11±4 months. Subjects averaged 49 years of age (range 33–69). Thirty percent was African–American, the rest Caucasian. Sixty-nine percent had 12 years of education or more. Ninety percent was employed, with 19% was in working class jobs. Performance status was 1 or 2 on a four-point scale, indicating minimal functional impairment for these women at the time of study enrollment.

Disease characteristics are

Discussion

This exploratory study of recurrent breast cancer patients shows that negative affectivity, when added to restriction of emotions, strengthens the prediction of shortened survival based on disease severity. Patients reporting low chronic anxiety differed in survival time, depending on their level of constraint, with low emotional constraint and low chronic anxiety characterizing those with longer survival than all others. Low reported chronic anxiety and high emotional constraint characterized

Acknowledgements

The authors would like to acknowledge the contributions to this project from: Margo Aaron, MSW, Ken Cowan, MD, Sharon Dym, Liz Ginexi, PhD, Martha Hunt, Kelsey Menehan, MSW, Julia Rowland, PhD, Robert Siegel, MD, Carlene Sipma-Dysico, MA, Ina Slaughter, Ilyse Spertus, and Julie Wade, MA.

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    ADAMHA grant K20 MH00906 to Karen Weihs, MD, supported this work. David Reiss, MD, served as mentor to Dr. Weihs for this award.

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