SOCIAL AND COGNITIVE INFLUENCES
ON ADAPTATION TO CANCER

SHARON MANNE, Ph.D., Member; Adjunct Professor, Mount Sinai School of Medicine, Ruttenberg Cancer Center, New York, NY

The research in our laboratory focuses on the impact of cancer and cancer risk on patients and their families. In particular, we are interested in social-environmental influences that affect how individuals cope with cancer and cancer risk, at all points along the cancer continuum. We study: women at risk for breast and ovarian cancer due to a strong family history of this disease and their husbands; men and women at risk for colon or rectal cancer due to a family history of this disease; adults who are diagnosed with breast, lung, prostate or ovarian cancer and their healthy partners; mothers of children undergoing risky cancer treatment procedures such as bone marrow transplant (BMT); and, long-term survivors of cancer.

Social and emotional support provided by family and friends plays a critical role in the adjustment of cancer patients to a variety of stressors encountered during the course of diagnosis and treatment. Spouses are particularly vulnerable as sources of emotional support for patients. Unfortunately, the stress of illness can negatively affect close relationships such that the support provided by family members can deteriorate as the demands of illness increase. Thus, at the very time when patients need the most support, it becomes increasingly difficult for family and friends to meet these needs. The goal of the proposed research is to understand this social support process and to develop and test interventions to bolster the quality of close relationships during and after cancer treatment.

Three research studies address these issues. The first study is a 6 month longitudinal study examining spousal supportive and negative behaviors (criticizing and avoiding the patient) on the coping and adaptation of colon, breast, lung, lymphoma, and prostate cancer patients. Patients and spouses are assessed at three time points during treatment. The second study seeks to examine support exchanges between women with breast cancer and their husbands to determine the interactional processes that convey support or criticism; this is accomplished by videotaping couples talking about cancer-related problems. These couples are followed over the course of cancer treatment and 18 months after treatment is complete. Data on communication styles will be used to examine which interactions are associated with patient ratings of poorer marital quality and psychological distress. The third study is a controlled clinical trial of a communication and coping skills intervention focused on the married couple that is designed to bolster the patient's well-being. Couples will be randomly assigned to either the intervention group or to standard psychosocial care. The content of the group will target: productive communication, particularly asking for and providing support; problem solving skills; and, coping with the illness and demands of treatment. Partners will be assessed using questionnaire methods pre- and postintervention, as well as six months postintervention.At this time, we have almost completed the second study, and are set to begin the intervention study in June 1999.

Progress in cancer treatment outcome has greatly increased the percentage of cancer survivors, particularly those diagnosed with colorectal (CRC) and prostate cancers. The overall five-year survival rate for CRC is currently 63%. When the disease is diagnosed in a localized stage, this percentage is increased to 84%. The statistics are even more promising for prostate cancer; the five-year survival rate is 87% overall, and 99% when diagnosed in a localized stage. Increasing numbers of cancer survivors has created an opportunity to examine the long-term impact of cancer survival on the quality of life.

To date, there has been relatively little attention given to psychosocial issues related to long-term colorectal and prostate cancer survivorship. Long-term survivors are defined as patients who have successfully completed treatment for the cancer, are at least 5 years from the initial cancer diagnosis, and have been cancer-free for at least one year. The majority of studies examining cancer survivorship have targeted breast cancer, Hodgkin's and post-BMT patients. The few studies that have examined CRC survivors have focused on short- and intermediate-term survivors (<5years). Studies examining prostate survivors have tended to include more long-term survivors (>5years). However, few of these have examined psycho-social issues related to prostate-specific side effects, focusing instead on global quality of life, which may not be a measure sensitive enough to detect specific areas of concern.

Furthermore, the literature on survivorship has emphasized psychosocial disability imposed by cancer; relatively few studies have analyzed cognitive processing, which refers to the thoughts and coping strategies of survivors that enable them to find some meaning in their experience. In this study, we will be examining the cognitive processing of long-term colorectal and prostate cancer survivors by assessing the prevalence of intrusive thoughts and memories, searching for meaning in the cancer experience, finding meaning, and re-appraising the experience. It is expected that a subgroup of survivors will continue to show symptoms of distress, desire to talk about their experience, and experience a reduced quality of life. Those evidencing less distress have found some meaning in the experience, and will feel that they have grown from the experience.

Study participants complete questionnaires, using an interview methodology, which assess prevalence of late effects of cancer and treatment, bother experienced by these effects, psychological distress, and cognitive processing of the event. To date, we have almost completed data collection on this study, with the "time one" assessment gathered from 270 survivors. We anticipate approximately 300 subjects will complete this study, and data analysis will be underway by the spring of 1999.

CRC is the fourth most commonly diagnosed cancer and is responsible for the second highest number of cancer deaths. For those with early stage disease, the five-year survival rate is 84%. For those with regional disease, the percentage drops to 63%. Only 7% of those presenting with metastatic disease will survive five or more years. Increasingly, attention has been focused on effective methods of early detection and prevention.

The lifetime risk of developing CRC is approximately 5% by age 50, with men and women being at equal risk. Individuals with one first-degree relative (FDR) who has been diagnosed with CRC are estimated to have an lifetime risk of 10%. For individuals with an FDR diagnosed at or before the age of 55 (considered intermediate risk individuals), the lifetime risk is estimated to be even greater, with estimates ranging from two to four times the risk level of the average risk person. Because of this increased risk, individuals with a FDR diagnosed with CRC are advised to undergo CRC screening beginning at age 40, which is a decade earlier than is recommended for average risk individuals. Unfortunately, participation in screening is relatively low, particularly in comparison with other cancers.

Few studies to date have examined the factors affecting participation in CRC screening programs for those with an intermediate risk for CRC. This study will attempt to determine the sociodemographic status, knowledge, health status, health history, social and media influence, physician influence, and psychological factors that are associated with the decision of intermediate risk individuals to participate in fecal occult blood testing (FOBT), flexible sigmoidoscopy, and colonoscopy.

We plan to recruit 490 siblings of FDR diagnosed at the age of 55 or younger for this study. To date, data has already been collected from approximately 40 siblings; this data reports only on factors influencing colonoscopy screening. The transtheoretical model (TTM) predicts that the subjects will differ on intention to undergo the screening procedure, with stages of intention ranging from precontemplation (not thinking about undergoing the procedure) to relapse/relapse risk (having undergone the procedure in the past, is currently not undergoing or at risk for stopping). This model also predicts that individuals falling into different stages will vary with regard to the pros and cons they attribute to the procedure.

BMT has been indicated to cause considerable distress for patients and their families. This may be due to the fact the BMT is imminently life-threatening. Mothers, in particular, experience considerable distress from having a child undergo BMT. Not only do they evidence more distress from BMT than from other, more traditional, cancer treatments, they also show more distress than other family members. For these reasons, pediatric BMT serves as a model of a severe negative life-event for mothers and permits the examination of distress following such an event.

Little is known about the course of mothers' distress during and after BMT, as well as factors that may place mothers at an increased risk for adjustment problems. There is growing evidence from studies examining adjustment to trauma and well being following negative life-events that cognitive/social processing is critical to adjustment. According to models of cognitive/social processing, the psychosocial impact of severe negative life-events is related to how well an individual is able to integrate the event into his/her beliefs. The recovery and adjustment process can be stifled when talking about the event is limited by social constraints.

This study will examine the role of cognitive/social processing in maternal distress associated with BMT in the treatment of pediatric cancer. Subjects will consist of 509 mothers who will be recruited for a longitudinal design study, with assessments being given in the form of structured interviews two weeks before BMT hospitalization, during the acute BMT hospitalization, and at 6, 12 and 18 months post-BMT. The specific aims of the assessments are to: examine the course of psychological distress of the mothers; determine the role of cognitive and social processing in the development and maintenance of this distress during and after the child's BMT; and, assess how dispositional optimism, monitoring coping style, and prior negative life-events influence mothers' cognitive processing and development/maintenance of psychological distress. Results of this study will increase our understanding of the role of cognitive/social processing in adjustment to negative life-events and will have implications for the development of psychosocial interventions. This study has been underway since May; to date, we have collected data from approximately 20 mothers.

Ovarian cancer patients are at high risk for chronic psychological distress resulting from worries about an invasive aggressive cancer treatment, a relatively poor prognosis, the threat of persistent disease, and a significant impact on quality of life. To improve the quality of life for these women, support from others and effective coping are important. The aim of this pilot study is to examine the efficacy of a psychoeducational intervention to address these issues for a sample of 100 women with ovarian cancer. Participants will be randomly assigned to either a communication-coping skills intervention (five sessions) or a general health education intervention (control group, four sessions). Participants will complete questionnaires at three time points: pre-intervention, post-intervention and at a six month follow up.

MANNE, S. Intrusive thoughts and psychological distress among cancer patients: the role of spouse avoidance and criticism. J. Consult. Clin. Psychol. (in press).

MANNE, S., ALFIERI, T., TAYLOR, K., DOUGHERTY, J. Preferences for spouse support among individuals with cancer. J. Appl. Social Psychol. (in press).

MANNE, S., ALFIERI, T., TAYLOR, K., DOUGHERTY, J. Spousal negative responses to cancer patients: The role of social restriction, spouse mood, and relationship satisfaction. J. Consult. Clin. Psychol. (in press)

MANNE, S., PAPE, S., TAYLOR, K., DOUGHERTY, J. Spouse support, coping and mood among individuals with cancer. Ann. Behav. Med. (in press).

MANNE, S. Well-established treatments for procedure-related pain: Issues for future research and policy implications. J. Pediatr. Psychol. 24:149-151,1999.

MANNE, S., MILLER, D., MEYERS, P., STEINHERZ, P., WOLLNER, N., REDD, W.H. Difficulties completing treatment tasks among newly diagnosed children with cancer. Children's Health Care (in press).

MANNE, S., DOUGHERTY, J., VEACH, S., KLESS, R. Hiding worries from one's spouse: Protective buffering among cancer patients and their spouses. Cancer Res. Therapy and Control 8:175-88, 1999.

MILLER, D., MANNE, S., PALEVSKY, S. Acceptance of behavioral interventions by pediatric oncology parents and nurses. J. Pediatr. Psychol. 23:267-27, 1998.

MANNE, S. Cancer in the marital context: A review of the literature. Cancer Investigat. 16 (3):188-202, 1998.

MANNE, S., MILLER, D. Social support, social conflict, and adjustment among adolescents with cancer. J. Pediatr. Psychol. 23(2):267-271, 1998.

MANNE, S. Treatment adherence and compliance. In Handbook of Pediatric Psychology and Psychiatry, edited by R. Ammerman, J. Camp. Allyn & Bacon, NY, pp. 103-132, 1998.

REDD, W.H., DUHAMEL, K., VICKBERG, S., JACOBSEN, P., MANNE, S. Long-term adjustment in cancer survivors: Integration of classical conditioning and cognitive processing models. In Psychosocial Interventions and Cancer, edited by A. Baum, B. Anderson (in press).

^§   Fox Chase researcher

^a   J. Ostroff: Memorial Sloan-Kettering Cancer Center, 333 E. 59th Street, New York, NY 10022

^b   L. Norton, M. Massie, S. Winawer, A. Markowitz, J. Guillem, F. Boulad: Memorial Sloan-Kettering Cancer Center, New York, NY 10021

^c   R. Bakeman: Georgia State University, Atlanta, GA 30303

^d   P. Fraenkel: Ackerman Institute, New York, NY 10021

^e   G. Grana: Cooper Medical Center, Camden, NJ 08103

^f   K. Fox, J. Morris, N. Williams, J. Rombeau, E. Rosato: Hospital of the University of Pennsylvania, Philadelphia, PA 19104

^g   P. Crilley, J. Reynolds: Hahnemann University Hospital, Philadelphia, PA 19102

^h   R. Sugar: Warminster Hospital, Warminster, PA 18974

ⁱ   T. LaCouture: Medical College of Pennsylvania, Philadelphia, PA 19129

^j   W. Rakowski: Brown University, Providence, RI 02912

^k   B. Krevsky: Temple University Hospital, Philadelphia, PA 19122

l    W. Redd, K. DuHamel, A. Vlachos, J. Lipton: Mt. Sinai School of Medicine, New York, NY 10029

^m   J. Graham-Pole: University of Florida, Gainesville, FL 32601

ⁿ   D.R.Martini, M. Kletzel: Children's Memorial Hospital, New York, NY 10021

^o   G. Winkle: City University of New York Graduate Center, New York, NY 10001

^p   D. Main: Georgetown University, Washington, DC 20007

^q   S. Parsons: Dana Farber Institute, Boston, MA 02115

Illustrations or unpublished data in these reports should not be used without permission of the author.

Fox Chase Cancer Center

Scientific Report 1998