PSYCHOSOCIAL AND BEHAVIORAL MEDICINE PROGRAM

Recent developments in cancer research, molecular biology, and genetics provide promising new avenues for preventing and controlling cancer. Nevertheless, many lives are still lost unnecessarily every year to certain cancers that could have been prevented or controlled. The goal of our research is to make cancer prevention-control programs more effective by identifying the distinctive ways in which individuals make decisions, adjust to risk information, and carry out recommended screening, treatment, and follow-up regimens. Our efforts focus on the application of assessments and interventions that are specifically tailored to individual differences among patients. Toward this end, we have been conducting a series of interrelated projects to provide a systematic and comprehensive exploration of the psychosocial-biobehavioral links that underlie adaptive responses, across the spectrum of cancer risk and disease. The studies in our program are all conceptually derived from our integrative theory-based framework, the Cognitive-Social Health Information-Processing (C-SHIP) model. This model addresses how different types of individuals process information about cancer threats and prevention-control options. The CSHIP model recognizes that behavior is influenced by the individual's perceived vulnerability, self-efficacy, expectations, health values and goals, emotions, and coping strategies, as well as by aspects of the cancer threat, such as its probability and controllability. These factors need to be taken into account when designing assessments and interventions to facilitate complex decision-making, and to enhance long-term adherence to medical recommendations and adjustment to cancer threats.

In particular, we have identified two main styles of processing cancer risk feedback. Conceptually, we distinguish between monitors, who look for and amplify threat-related cues, and blunters, who distract from such cues and minimize their impact. Our work identifies the ways in which monitors and blunters differ in how they cope with cancer risk and disease information, and in how they respond to psychosocial interventions designed to facilitate health protective decisions and behaviors. Towards this end, we have devised and validated the Monitor-Blunter Style Scale to distinguish between these patterns of response. This approach enables us to develop and evaluate the efficacy of tailored interventions, which are designed to help monitors versus blunters overcome the distinctive cognitive, emotional, and practical barriers that undermine this use of cancer prevention-control regimens.

We are currently exploring decision-making, adherence to recommended routine and innovative regimens, adjustment to cancer feedback, and biobehavioral linkages, from cancer risk through survivorship. The studies share a common focus on populations with a critical need for cancer prevention-control services, such as individuals with a family history of cancer, individuals from traditionally underserved groups, and individuals dealing with treatment and management regimens. Our ongoing work focuses on genetic and biomarker risk feedback (breast/ovarian, prostate, and lung cancers), cervical risk feedback and behavioral correlates in underserved populations, cancer prevention and control outreach efforts, early stage treatment decision-making (prostate and breast cancers), and prevention strategies for high-risk groups.

Genetic testing research for cancer susceptibility, based on the recently identified BRCA1 and BRCA2 genes, is confronting many presently healthy women with the option of receiving feedback about their breast and ovarian cancer prospects. We have shown in our work that it is difficult for individuals to accurately process this feedback and to rationally judge their options. Therefore, we have developed an enhanced counseling intervention, devised from the CSHIP model, to facilitate well-informed decisions for BRCA1 and BRCA2 among high-risk women. In this procedure, the genetic cancer-testing candidate is helped with cognitively and emotionally anticipating scenarios about alternative potential outcomes of testing outlined in the informed consent process. The goal is to enable the individual to vividly imagine and role-play the personal and social impact on herself, her family, and her future, in the context of a brief, structured supportive counseling session. The utility of this Cognitive-Affective Preparation (CAP) procedure is being evaluated systematically, in a randomized controlled trial, with General Health Information (GHI) serving as the comparison condition.

Emerging guidelines of medical care now include recommendations for routine prostate cancer screening for first degree relatives (FDRs) of prostate cancer patients, beginning as early as 40 years of age. Our research shows that in comparison with non FDRs, FDRs perceive themselves to be at greater risk for prostate cancer, exaggerate their lifetime risk for the disease, and believe that less can be done to prevent its development. Yet, they are no more likely to be screened than are non-FDRs. Our ongoing study, therefore, targets healthy FDRs being recruited for participation in the recently implemented, state-of-the-art Prostate Risk Assessment Program (PRAP) at Fox Chase. The study investigates the utility of a C-SHIP based enhanced counseling intervention, modeled on well-established clinical techniques and research, which is administered following standard counseling. The goal of this procedure is to facilitate the individual's processing of, and preparation for, prostate cancer risk feedback and its consequences. To equate for the effects of additional time, attention, and review of information provided in enhanced counseling, the standard counseling plus CAP intervention is being compared to standard counseling plus GHI, in a randomized controlled trial.

Lung cancer is the leading cause of cancer deaths in the United States, with an estimated 160,000 deaths attributable to this disease and an estimated 180,000 new cases projected for 1998. Innovative medical technologies (i.e., fiber optic bronchoscopy imaging, and CYP1A1 genotype analysis) provide individuals with risk feedback in terms of 1) the presence or absence of cancer in situ, and 2) CYP1A1 biomarker status. Guided by the C-SHIP model, the overarching goal of this research is to explore the behavioral and psychological impact of risk feedback among chronic smokers in terms of the impact on adherence to recommended cancer screening, diagnostic, and behavior change regimens. The data will be used to develop, implement, and evaluate an intervention that will be provided during a window of opportunity (i.e., risk feedback). This process is designed to facilitate behavior change and screening adherence, by tailoring risk feedback to the individual's psychological profile.

An important focus of our work with cervical risk populations has been to explore the efficacy of brief counseling interventions for helping women with abnormal Pap smear results adjust and adhere to diagnostic follow-up (colposcopy), particularly in low-income inner-city populations, who are most at risk for the disease. The results show that telephone counseling in the week prior to the initial diagnostic follow-up appointment increases both initial and long-term adherence compared with telephone confirmation and standard care alone. In related work, we are comparing the impact of a brief on-site enhanced counseling intervention with a health education intervention, designed to equate for time and attention, and a usual care group, which does not receive any intervention. Both of the interventions are designed to facilitate knowledge of cervical cancer risk and management. However, the counseling intervention also targets emotional and practical barriers to diagnostic follow-up (through relaxation and role-play techniques). In a further study, we are exploring the impact of the psychological framing of cervical cancer-risk information and recommendations. The counseling protocol is designed to emphasize either the cost of non-adherence to recommended screening and health-protective regimens (loss frame), the benefit of adherence to such regimens (gain frame), or a neutrally framed message. Results indicate that blunters show greater knowledge and adherence in the loss-framed condition, without suffering an emotional toll. Conversely, monitors experience greater distress when information is framed in terms of loss, without an increase in knowledge or adherence.

Certain strains of human papilloma-viruses (HPVs) play an important role in the etiology of cervical cancer. We are examining longitudinally the interrelations among possible relevant intervening psychoneuroimmunologic parameters in low-income women with low-grade cervical dysplasia and are exploring the implications for disease status over time. In a recently completed arm of this study, we found that sleep quality was significantly associated with the number and percentage of helper T cells (CD4⁺), as well as with the percentage of cytotoxic/suppressor T cells (CD8⁺) among HPV-infected women, after controlling for background and behavioral confounder variables (i.e., age, smoking status, and drug use). Even after controlling for the variance accounted for by depression, increased sleep quality was associated with a greater number and percentage of helper T cells. We are currently focusing on a promising complementary medicine strategy, hypnotherapy, for improving sleep quality, reducing distress, and improving immune function among low-income women with HPV infection.

Smoking accounts for approximately one in every five deaths in the Unites States, totaling more than 419,000 deaths each year. Cigarette smoking is associated with a number of adverse health effects, including an increased risk of cervical dysplasia. Our pilot work indicates that at least 50% of women undergoing follow-up examination for an abnormal Pap smear result are smokers, indicating a need for innovative tobacco control outreach programs. Consistent with existing guidelines for smokers, our ongoing study assesses the utility of a theory-driven, tailored smoking cessation intervention provided at a teachable medical moment (i.e., at the time of diagnostic follow-up for an abnormal Pap smear result). Women are randomized to receive either the enhanced smoking cessation intervention or a matched control group that equates for time, attention, and format. Guided by the C-SHIP model, the smoking cessation intervention builds on well-established cognitive-behavioral techniques, tailored to monitoring style and stage of readiness to quit.

Few services exist to help women make informed decisions about whether or not they are appropriate candidates for genetic risk assessment programs. The Cancer Information Service (CIS) is an existing informational resource that is available to the public and can be utilized to meet this growing need. Our ongoing study focuses on female cancer patients, their families, and the interested public who call the CIS for information on breast cancer and genetic risk; calls evaluated are received at the Region 4 CIS, serving eastern Pennsylvania, New Jersey and Delaware. Since 1994, there has been more than a three-fold increase in the number of inquiries about genetics in this office. Callers are randomized to two groups: either the standard CIS intervention, which focuses on basic information on genetics and breast cancer, as well as referrals to approved high-risk programs or to an enhanced, CSHIP-guided intervention, which is designed to increase callers' understanding of the kinds of information that are required to determine inherited risk, their own personal family history of cancer, and the benefits and limitations of genetic testing.

With employees spending over one-third of their day at the workplace, the worksite has come to be acknowledged as an important site to offer health promotion, and cancer prevention and control initiatives. However, as managed care companies have come to dominate workplace health insurance services, cancer screening and prevention educational programs in the workplace have dramatically declined. The overall goal of our research is to establish a theory-guided comprehensive cancer control program in the workplace, to serve as a model for use in industry across the state. The aim is to improve employees' knowledge about their risk factors for cancer, and to enhance participation in recommended cancer risk programs. This intervention, in turn, should facilitate modification of behavioral risk for cancer, improve early detection, and reduce morbidity and mortality rates. A particular focus is to identify the adherence patterns of monitoring versus blunting styles, and to develop messages tailored to these groups.

Patients diagnosed with early-stage prostate cancer are faced with important treatment decision-making. Yet, little is known about the psychosocial factors that influence decision making and adjustment among these individuals. Guided by the CSHIP model, our ongoing study is designed to fill this empirical gap by obtaining detailed, longitudinal assessments of the determinants and consequences of the decision making among patients diagnosed with early-stage prostate cancer. The findings will be used to develop interventions and print materials to facilitate treatment decision making and enhance adjustment to prostate cancer.

Ovarian cancer is associated with the highest mortality rate of the gynecological cancers. Women with a family history are at especially high risk of developing the disease. Since the efficacy of available detection regimens is limited, prophylactic oophorectomy (i.e., the surgical removal of healthy ovaries) has emerged as an important preventive option for these individuals. Yet, few data are available on how to help patients process and make decisions about undergoing prophylactic surgery. Our preliminary findings indicate that the response to ovarian risk is influenced by the individual's characteristic attentional style: monitors, who feel more vulnerable and pessimistic about their prospects than blunters, are more likely to choose surgical intervention, without fully anticipating the psychological and medical consequences of their decision. Guided by the C-SHIP model, we are conducting a longitudinal assessment of healthy individuals participating in the well-established Family Risk Assessment Program (FRAP) at Fox Chase to systematically explore the cognitive and emotional factors that underlie how women understand, and make decisions about, preventive surgery. These findings will be used to refine an enhanced counseling intervention, designed to enable the individual to realistically weigh her options, and to reach a well-informed decision for herself.

In recent years, the use of chemoprevention drugs has become increasingly important in the prevention of certain types of cancers among at-risk populations. Tremendous resources have been spent recruiting individuals to these trials, with similar efforts expended to maintain participation in the study protocols. Yet, enrollment into trials is difficult, calling into question the scientific integrity of the research. To date, little is known about the psychological factors that lead an individual to volunteer for such trials and to adhere to the study protocols. In ongoing work, we are using the organizing framework of the C-SHIP model to 1) identify the psychological variables underlying the decision to enter a chemoprevention trial and to adhere to the study protocol, with specific attention given to individual differences in motivations, and 2) to develop tailored messages aimed at increasing participation in, and adherence to, these trials.

BRUNER, D.W., BAFFOE-BONNIE, A., MILLER, S.M., DIEFENBACH, M., TRICOLI, J., DALY, M., PINOVER, W., STOFEY, J., ROSS, E., BALSHEM, A., MALICH, J., SHIRELY, K., ENGSTROM, P., HANKS, G. A prostate cancer risk assessment program: A model for early detection of prostate cancer. Oncology (in press).

DIEFENBACH, M., MILLER, S. M., DALY, M. Specific worry about breast cancer predicts mammography use in women at risk for breast and ovarian cancer. Health Psychol. (in press).

ENGSTROM, P.F., CLAPPER, M., EVANS, A., ORLEANS, C.T., SCHNOLL, R.A., MILLER, S.M., SIGURDSON, E. Prevention of tobacco-related cancers. In Cancer Medicine (4^th edition), edited by J.F. Holland, R.C. Blast, Jr., D.L. Morton, E. Frei III, D.W. Kufe. William and Wilkins, Baltimore, MD (in press).

MILLER, S.M. Monitoring and blunting of threatening information: Cognitive interference and facilitation in the coping process. In Stress and coping, edited by S. Trilivas. Ellinika Grammat, Athens. (in press).

ROUSSI, P., MILLER, S.M., SHODA, Y. Discriminative facility in the face of threat: Relationship to psychological distress. Psychol. Health (in press).

SAMAROFF, A., LEWIS, M., MILLER, S.M. (Editors) Handbook of Developmental Psychopathology (2nd Edition). Lawrence Erlbaum, New Jersey (in press).

SAVARD, J., MILLER, S.M., MILLS, M., O'LEARY, A., DOUGLAS, S., MANGAN, C.E., BELCH, R., WINOKUR, A., HARDING, H. The influence of sleep quality and depression on immunocompetence in low-income women at risk for cervical cancer. Psychosom. Med. (in press).

SCHNOLL, R.A, HARLOW, L.L., BRANDT, U., STOLBACH, L.L. Using two factor structures of the mental adjustment to cancer (MAC) scale for assessing adaptation to breast cancer. Psych-Oncol. 7:424-435, 1998.

SCHNOLL, R.A, HARLOW, L.L., STOLBACH, L.L., BRANDT, U. A structural model of the relationships among stage of disease, age, coping, and psychological adjustment in women with breast cancer. Psych-Oncol. 7:69-77, 1998.

SHODA, Y., MISCHEL, W., MILLER, S.M., DIEFENBACH, M.A., DALY, M., ENGSTROM, P.F. Psychosocial interventions and genetic testing: Facilitating informed decisions about BRCA1/2 cancer susceptibility. J. Clin. Psychol. in Med. Settings. 5:3-17, 1998

FANG, C.Y., SIDANIUS, J., PRATTO, F. Romance across the social status continuum: Interracial marriage and the ideological asymmetry effect. J. Cross-Cult. Psychol. (in press).

MILLER, S.M. Applications of the Monitoring Process Model. Applied Psychol.: An International Review. (in press).

MILLER, S.M., FANG, C.Y., DIEFENBACH, M.A., BALES, C.B. Tailoring psychosocial interventions to the individual's health information processing style: The influence of monitoring versus blunting in cancer risk and disease. In Psychosocial Interventions and Cancer, edited by A. Baum, B. Anderson. American Psychological Association, Washington, DC (in press).

MILLER, S.M., BUZAGLO, J.S., GREEN, V., SIMMS, S. L., BALES, C., MANGAN, C.E., SEDLACEK, T.V. Monitoring styles in women at risk for cervical cancer: Implications for the framing of health-relevant messages. In Special Issue Innovative Approaches to Health Behavior Change, Ann. Behav. Med. (in press).

MILLER, S.M., SCHNOLL, R.A. Stress and coping in the cancer context. In Handbook of emotion, edited by M. Lewis and J. Haviland. Plenum Press, NY (in press).

MILLER, S.M., DIEFENBACH, M.A. The Cognitive-Social Health Information Processing (C-SHIP) model: A theoretical framework for research in behavioral oncology. In Perspectives in behavioral medicine, edited by D. Krantz. Lawrence Erlbaum, NJ, pp. 219-244, 1998.

MILLER, S.M., GREEN, V., BALES, C.B. What you don't know can hurt you: A cognitive-social framework for understanding children's responses to stress. In Stress and Soothing, edited by M. Lewis, D. Ramsay Lawrence Erlbaum, NJ, pp. 257-292, 1998.

MILLER, S.M., MISCHEL, W., SCHROEDER, C.M., BUZAGLO, J., HURLEY, K., SCHREIBER, P., MANGAN, C.E., SEDLACEK, T.V. Intrusive and avoidant ideation among females pursuing infertility treatment. Psychol. Health 13:847-858, 1998.

^§   Fox Chase researcher

^a   W. Helm, E. Hernandez: Temple University Hospital, Philadelphia, PA 19122

^b   S. Douglas: Hospital of the University of Pennsylvania, Philadelphia, PA 19104

^c   A. O'Leary: Centers for Disease Control, Atlanta, GA 30333

^d   C. Mangan, R. Belch, T. McGinnis, R. Guintoli: Mangan-Riva Associates, Philadelphia, PA 19106

^e   A. Winokur: University of Connecticut at Storrs, Storrs, CT 06268

^f   J. Palefsky, S. Kapoor: University of California at San Francisco, San Francisco, CA 94143

^g   M. Mills: University of Chicago, Chicago, IL 60637

^h   J. Savard: Laval University, Quebec City, Quebec

ⁱ   H. Leventhal: Rutgers University, New Brunswick, New Brunswick, NJ 08903

^j   G. Grana: Cooper Hospital, Camden, NJ 08103

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

Fox Chase Cancer Center

Scientific Report 1998