STRESS MANAGEMENT INTERVENTION EFFECTS ON BIOBEHAVIORAL PROCESSES IN BREAST CANCER PATIENTS UNDERGOING MEDICAL TREATMENT Biobehavioral oncology research focuses on (1) basic research examining interactions between stress physiology, including neuroendocrine processes, immunologic-cytokines and tumor biology; and (2) clinical research evaluating the associations of psychosocial processes and interventions with changes in psychological and physiological indicators that are relevant for quality of life and health outcomes. This talk will focus on the latter approach by describing the rationale, design, extant results, and future research plans for a program of research aimed at testing the effects of cognitive behavioral stress management intervention on facilitating positive adaptation during and after medical treatment for breast cancer. These studies provide evidence for the effects of stress management intervention on psychosocial stress processes and quality of life, neuroendocrine and immunologic changes, which may be relevant for disease promotion. Adjusting to a new diagnosis of cancer, dealing with surgery and anticipating the physical challenge of adjuvant therapy are multiple stressors that can overwhelm the adaptational efforts of persons dealing with cancer. Poorer psychosocial adaptation may be evident in emotional and interpersonal disruptions that do not resolve and these may be accompanied by poorer physiological adaptation evident in elevations in hypothalamic pituitary adrenal (HPA) hormones such as cortisol and decrements in cellular immune indicators, which could have effects on future health. We present two sets of studies highlighting the rationale, design and major results from randomized trials of group-based cognitive behavioral stress management (CBSM) intervention in individuals recently undergoing treatment for breast cancer. We review the methodological issues involved in the design of psychosocial interventions for cancer patients in order to test effects on psychological adaptation, physiological adaptation and mediational processes that might explain the effects of the intervention on these outcomes. Over the past decade we developed and tested the effects of a group-based CBSM intervention on psychosocial and physiological adaptation among over 300 women diagnosed with early-stage breast cancer recruited in the midst of their medical treatment. We designed each research study to test the efficacy and mechanisms underlying psychosocial interventions in the context of breast cancer treatment. The CBSM intervention was chosen since it provides training in relaxation, coping skills, and other stress management techniques, in a supportive group. These elements were all deemed optimal for women being treated for breast cancer. In choosing a sample we wanted to include participants who were dealing with a particularly stressful point in their treatment. Therefore these studies recruited women with Stage I to III disease who were then randomized 4 to 8 weeks after surgery to either a 10-week CBSM group or a one-day CBSM seminar and followed across the period of adjuvant therapy to test whether stress management can facilitate psychosocial and physiological adaptation after adjuvant therapy. Assessments were made at baseline, and 6 and 12 months follow-up using indicators of positive and negative psychological adaptation and physiological adaptation. Analyses focused first on establishing the efficacy of the intervention, then testing hypothesized mediators and ultimately using this information to conduct dismantling studies to isolate active ingredients and formulate cost-effective, shorter and more portable versions of the intervention. In a first wave of studies we demonstrated that women randomized to CBSM showed increases in positive adaptation (benefit finding and optimism) and decreases in depression, findings that were most pronounced in women initially presenting with greater degrees of pessimism and depressive symptoms, respectively. This suggested that these forms of intervention are likely to have their greatest psychosocial impact on populations that are in greatest need. These psychological changes were paralleled by decreases in evening serum cortisol levels during the intervention period, and increases in lymphocyte proliferative responses to anti-CD3 (T-cell receptor) challenge up to 3 months after the conclusion of the intervention. The intervention also affected increased T-helper-Type 1 (Th1) cytokine production (g-interferon) by anti-CD3 stimulated peripheral blood mononuclear cells. The largest changes in these physiologic measures were observed in women reporting the greatest increase in positive adaptation (benefit finding). In the second wave of studies we recruited women representing a wider range of distress and extended the period of follow-up. Using Latent Growth Modeling analyses these studies showed that women assigned to the 10-wk CBSM intervention showed decreased anxiety symptoms, negative affect, intrusive thoughts about cancer and interpersonal disruption; and increased positive psychosocial adaptational outcomes such as benefit finding, positive affect and positive states of mind up to 9 months after the conclusion of the intervention. Mediational analyses showed that increases in emotional processing and perceived relaxation skills during the intervention accounted for the majority of these psychological outcomes. In sum across these two trials, CBSM modulated several psychosocial adaptation indicators while increases in benefit finding predicted changes in endocrine and immunologic functioning after the intervention. Secondary analyses revealed that women who attended 4 to 6 CBSM sessions showed similar effects to those attending 8 to 10 sessions suggesting that at shorter form of the intervention might be effective. A recently initiated study will dismantle the elements of this multi-modal intervention by comparing the effects of a 5-week relaxation training group, a 5-week cognitive behavioral group, and a 5-week attention control group on similar indices of psychosocial and physiological adaptation in women undergoing treatment for breast cancer. These studies represent a process of testing for intervention effects on psychosocial and physiological indicators during the period of active medical treatment for breast cancer, testing mediational hypotheses during efficacy trials, and then doing dismantling studies where proposed mediators are manipulated experimentally. Throughout many of these studies there was evidence that psychosocial changes during intervention were paralleled by changes in physiological indicators that may have implications for quality of life and physical health over time. Long-term follow-up studies monitoring quality of life and biomarker indicators of diseases activity will test whether these effects are durable and clinically important.
- American Association for Cancer Research