APOS Clinical E-Mail Update #15
7 February 2005

In this Update:

Do patients and couples grow after the trauma of a cancer diagnosis?

Manne S, Ostroff J, Winkel G, Goldstein L, Fox K, and Grana G.  Posttraumatic growth after breast cancer: patient, partner, and couple perspectives.  Psychosomatic Medicine. 2004;66:442-454.

The term posttraumatic growth is often used to describe the positive changes individuals may experience following a traumatic event.  Cancer is increasingly being considered such an event; upwards of 90% of patients have reported positive changes associated with their cancer experience.  Research to date has failed to adequately address several issues, however.  These include how early after a diagnosis this growth may begin, the longitudinal course of posttraumatic growth, what factors may contribute to posttraumatic growth, and whether posttraumatic growth is restricted to the individual that directly experiences the event.  In an effort to address these perceived shortcomings, the authors of this study surveyed 162 women and their partners over a period of 1.5 years following a breast cancer diagnosis.  They also examined the association between posttraumatic growth and cognitive processing, emotional expression, and emotional processing (from cognitive-affective-social processing theories) in the course of posttraumatic growth.  These factors were assessed at three time points: soon after surgery, 9, and 18 months after.

Researchers found that for both patients and partners, posttraumatic growth increased consistently over 1.5 years. The patients reportedly significantly greater posttraumatic growth than partners at all time points.  Whether this is due to the simple fact that the partners in this case were men and women generally tend to report greater posttraumatic growth anyway is not know.

For the patients, younger age, attempts to contemplate potential reasons for developing breast cancer, and more emotional expression shortly after surgery, were significantly associated with posttraumatic growth.  For the partners, younger age, more intrusive thoughts, more positive reappraisal, and emotional processing shortly after their partnerís surgery were significantly associated with posttraumatic growth.  An increased sense of personal strengths and new possibilities for life were the domains of growth which demonstrated the greatest gains.

The particular strengths of this study are three in number: one, it is the only longitudinal study of posttraumatic growth in cancer patients to date, two, it attempts to address the question of how soon after diagnosis an individual begins to report growth, and three, it examines posttraumatic growth in couples, not just the patients themselves.  It greatest shortcoming, as the authors themselves note, is that the research does not address whether posttraumatic growth is associated with other psychological outcomes.  In other words, does posttraumatic growth ultimately translate into such things as a greater sense of well being or less psychological distress? — KD

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Can negative reactions from others prevent processing of stressful information like a risk of cancer?

Schnur JB, Valdimarsdottir HB, Montgomery GH, Nevid JS, and Bovbjerg DH.  Social constraints and distress among women at familial risk for breast cancer.  Annals Beh Med. 2004;28:142-148. 

The social cognitive processing model posits that social constraints, that is, negative or unsupportive reactions from others, may impair a personís ability to successfully process stressful events.  Previous research has demonstrated that social constraints are related to higher levels of psychological distress in cancer patients.  Avoidance is one of several constructs that has been proposed to explain this relationship.  In this study, the authors sought to determine whether a positive family history of breast cancer was related to higher levels of cancer-specific distress and general psychological distress and whether avoidance mediated this relationship.  Sixty female medical center employees with one or more first-degree relatives with breast cancer participated in the study.  Despite the ethnic diversity of the sample and the fact that approximately half were married, the majority of the women were younger than 50 years of age, well educated, and employed in a professional or managerial position.  As hypothesized, social constraints were found to be positively related to cancer-specific distress and general distress.  Avoidance partially mediated the relationship. These findings are consistent with the social cognitive processing model. The correlational nature of the study precludes any conclusion about whether social constraints lead to avoidance, which in turn leads to distress. Nevertheless, the findings do suggest potential targets for intervention: decreasing a personís social constraints, their level of avoidance, or both.  With its relatively neat and simple design, this study helps to clarify the role of avoidance in predicting psychological distress. — KD

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Does demoralization, health anxiety, and alexithymia add information about breast cancer patients?

Grassi L, Rossi E, Sabato S, Cruciani G, Zambelli M.  Diagnostic criteria for psychosomatic research and psychosocial variables in breast cancer patients.  Psychosomatics 2004;45:483-491.

Twelve factors in psychosomatic research, health anxiety, thanatophobia, demoralization, irritable mood, illness denial, type A behavior, disease phobia, functional somatic symptoms secondary to a psychiatric disorder, persitent somatization, conversion syndrome, anniversary reaction, and alexithymia are brought together in a semi-structured interview for Diagnostic Criteria for Psychosomatic Research (DCPR). It was interesting to see how these related to coping with cancer and cancer related concerns and quality of life in cancer patients. Grassi et al examined the presence of these syndromes in patients with breast cancer (n=105) and found that those with DCPR syndromes had more cancer-related worries and poorer quality of life than those who did not have a DCPR syndrome diagnosed. Some syndromes of DCPR paralleled the subscales of the Mini-Mental Adjustment to Cancer (Mini-MAC) scale. Health anxiety correlated with anxious preoccupation coping style, demoralization related to hopelessness, and alexithymia related to avoidance subscales. The DCPR syndromes were more common in patients receiving chemotherapy and radiation treatment. Two-thirds of breast cancer patients showed DCPR syndromes, particularly health anxiety, demoralization, and alexithymia. They excluded the dimensions of the DCPR that would apply to comorbid somatoform disorders

The present study used the criteria of the DCPR to define demoralization. These are feelings of having failed to meet oneís own expectations or those of other people, inability to cope with some pressing problems, feelings of helplessness, hopelessness, and/pr giving up. These feelings of demoralization had been prolonged and generalized for more than one month and had antedated the physical disorder. They did not used the criteria of Kissane et al, which describes demoralized cancer patients as those who do not have clinical depression but have a cognitive stance over two weeks or more of hopelessness or loss of meaning and purpose in life, pessimism, helplessness, sense of being trapped, personal failure, or loss of a sense of a worthwhile future; conative absence of drive or motivation to cope differently, associated features of social alienation or isolation and lack of support. — DG

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Tamoxifen metabolites vary because of antidepressants, but does it make a difference?

Jin Y, Desta Z, Stearns V, Ward B, Ho H et al.  CYP2D6 genotype, antidepressant use, and tamoxifen metabolism during adjuvant breast cancer treatment.  J National Cancer Institute 2005;97:30-39.

The importance of these findings hinges on the clinical relevance of changes in tamoxifen metabolite concentrations. The clinical relevance is not known at this time.1 Antidepressant medications that inhibit CYP2D6 cause after 4 months lower concentrations of endoxifen, a metabolite of tamoxifen. So, fluoxitene, paroxetine, and to a lesser extent venlafaxine may change the level of these metabolites.  The response to tamoxifen has not been linked to serum levels of tamoxifen.  Metabolites are active in vivo, however. Endoxifen has that same potency in vitro as 4-hydroxytamoxifen in suppressing estrogen-dependent breast cancer cell growth and gene expression. This compound 4-ydroxytamoxifen is 10 times more potent than tamoxifen as an estrogen an antagonist in vitro. Mean steady state plasma concentration of endoxifen is 6.8 times higher than 4-hydroxytamoxifen concentrations. CYP2D6 gene polymorphisms also affected the endoxifen levels.

There are other serotonin reuptake inhibitors like citalopram or escitalopram that do not significantly inhibit CYP2D6. — DG

1. Goetz MP, Loprinzi CL. A hot flash on tamoxifen metabolism. J National Cancer Inst 2003;95:1734-1735.

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Does simple optimism lead to a better outcome for lung cancer patients?

Schofield P, Ball D, Smith JG, Borland R, OpBrien P et al.  Optimism and survival in lung carcinoma patients.  Cancer: 2004;100, 1276-1282.

Two questionnaires assessing optimism were given to 204 lung cancer patients participating in a randomized trial that compared accelerated and conventional radiotherapy with and without carboplatin chemotherapy. Treatment reduced optimism slightly after treatment, but pre-treatment optimism and progression-free survival did not correlate. Pre-treatment optimism did not related to overall survival either. — DG

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How can we get people to stop bad behaviors that promote cancer?

Gotay CC.  Behavior and cancer prevention.  J Clin Oncol 2005;23:301-310.

This is a comprehensive review of the effects of behavioral risk factors on cancer incidence as well as behavioral interventions for cancer prevention. Tobacco use, diet, physical activity, and obesity/energy balance are all linked to cancer. The strongest case for the role of behavioral interventions is the case that interventions that foster smoking cessation reduce the risk of cancer. The building of translational research to tailor individual interventions offers considerable promise. — DG

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Do patients with glioma get antidepressants?

Change SM, Parney IF, Huang W, Anderson FA, Asher AL et al.  for the Glioma Outcomes Project Investigators.  Patterns of care for adults with newly diagnosed malignant glioma. J Amer Med Assoc 2005;293:557-564.

The Glioma Outcomes Project investigators are working to provide benchmark data to enable comparison of individual practice patterns and outcomes for grade III and IV malignant glioma, a poor outcome tumor for which there is a dearth of evidence-based studies. As they outline the standard of care supported in the literature, they point out that antidepressants require further investigation to clarify whether they are appropriate in the care of glioma patients.Thirteen percent of patients enrolled in this project (n = over 500) had depressive symptoms, but only 29% of those symptomatic and 7% of all newly diagnosed patients were given antidfepressant medication.  Both antidepressants and anti-epileptics were given to 35 patients. The evidence does not support the use of anticonvulsants in patients who have no history of seizure. The role of antidepressant medication in this population is important to clarify further and highlights the role of trained providers attentive to the appropriate treatment of clinical depression in this population with a devastating injury and neuropsychiatric deficit. — DG

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DG:  Donna B. Greenberg, MD, Associate Professor of Psychiatry at Harvard Medical School and Psychiatric Consultant in the Massachusetts General Hospital Cancer Center, Dana Farber Partners Cancer Care

KD:  Kristine Donovan, PhD, MBA, Assistant Professor, DIO, Moffitt Cancer Center at the University of South Florida