Quality of Life and Breast Cancer: Relationship to Psychosocial Variables potx

Quality of Life and Breast Cancer:
Relationship to Psychosocial Variables
ᮢ
Shauna L. Shapiro
University of Arizona, Department of Psychology
ᮢ
Ana Maria Lopez
University of Arizona Cancer Center
ᮢ
Gary E. Schwartz, Richard Bootzin, Aurelio J. Figueredo
University of Arizona, Department of Psychology
ᮢ
Carrie Jo Braden
University of Texas College of Nursing
ᮢ
SarahF.Kurker
University of Arizona Cancer Center
The aim of this article is to shed more light on the relationship between
quality of life and aspects of the psychosocial experience for women with
breast cancer. The literature is briefly reviewed, including highlights of the
psychosocial consequences of cancer, an exploration of the relationship of
psychosocial variables to cancer, and a brief review of psychosocial inter-
ventions for cancer. Further, preliminary findings of an on-going NCI study
are introduced. Finally, clinical implications are discussed. The purpose
This article was supported in part by the National Institute of Health, National Cancer Institute, Bethesda
Maryland (grant number: 1 RO3 CA83342–01).
The authors would like to acknowledge the individuals who provided assistance in this research. Our greatest
appreciation is extended to the women participating in the study. We also are most grateful to Jon Kabat-Zinn,
Saki Santorelli, Elana Rosenbaum, Ferris Urbanowski, and the staff of the Center of Mindfulness in Medicine,
Health Care and Society, University of Massachusetts Medical Center for invaluable guidance and support. We
express appreciation to Joseph Denucci and the staff at Miraval for generously donating resources. We also

deeply thank Elana Rosenbaum and Natasha Korshak for their contribution to the MBSR intervention. Finally,
we would like to acknowledge Hal Arkowitz for his valuable editorial comments.
Correspondence concerning this article should be addressed to: Shauna L. Shapiro, Department of Psychology,
University of Arizona, Tucson, AZ 85721–0068; e-mail
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 57(4), 501–519 (2001)
© 2001 John Wiley
&
Sons, Inc.
of this article is to provide a context and foundation on which future
researchers and clinicians can build. Ultimately, we suggest that the bio-
medical model of disease, though crucial, does not take into account all of
the complex factors involved in cancer. The current literature lends sup-
port to the argument that a broader, more integrative framework, which
includes psychosocial factors, is needed. © 2001 John Wiley & Sons,
Inc. J Clin Psychol 57: 501–519, 2001
Keywords: breast cancer; psychosocial variables
The diagnosis of breast cancer, the most common type of cancer amongAmericanwomen,
elicits greater distress than any other diagnosis, regardless of prognosis (National Cancer
Institute [NCI], 1997; Stechlin & Beach, 1966; Vinokur, Threatt, Caplan, & Zimmerman,
1989). The aim of this article is to shed more light on the relationship between quality of
life and aspects of the psychosocial experience for women with breast cancer. Further, we
hope to provide information that will help health care professionals better understand
quality of life and psychosocial issues for women with breast cancer in attempt to aug-
ment clinical interventions and care. Ultimately, we suggest that the biomedical model of
disease, though crucial, does not take into account all of the complex factors involved in
cancer. We posit that a broader, more integrative framework, which includes psycho-
social factors, is needed.
We first highlight psychological and psychosocial issues associated with breast can-
cer, and then underscore specific psychosocial variables that may play a role in the dis-
ease. Further, we bring to light the current literature of psychosocial interventions for

patients with cancer. We then introduce preliminary research from an on-going study
funded by the National Cancer Institute (NCI). This is a pilot study intended to explore
psychosocial factors and quality of life, preparatory to embarking on a larger scale, long-
term study. Finally, we discuss clinical implications in an attempt to lend greater under-
standing to the complexities surrounding the relationship between quality of life and
psychosocial issues for women with breast cancer.
Psychosocial Issues and Breast Cancer
Researchers in the field agree that in general the diagnosis of cancer elicits greater dis-
tress than any other disease. The literature documents numerous negative psychological
consequences for patients including depression (Meyerowitz, 1980), anxiety (Ervin, 1973),
and hostility and anger (Vachon & Lyall, 1976). Earlier observational reports (Bard,
1955; Bard & Sutherland, 1952; Renneker & Cutler, 1952) were confirmed by cross-
sectional studies finding high levels of depression, sadness, anger, frustration, panic and
anxiety, and suicidal ideation (Grandstaff, 1976; Jamison, Wellisch, & Pasnau, 1978).
Depression is the most prevalent psychological problem for cancer patients (Dero-
gatis et al., 1983; Lansky et al., 1985), and anxiety is second in frequency (Derogatis
et al., 1983). One-third of women may experience considerable psychological morbidity
in the first two years after treatment (Dean, 1987; Morris, Greer, & White, 1977). Those
at greatest risk are women with a history of psychiatric illness (Bloom et al., 1987;
Penman et al., 1987).
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Journal of Clinical Psychology, April 2001
Distress varies in level of intensity depending on severity of disease as well as phase
of treatment (Simonton & Sherman, 1998). The greater levels of distress are positively
associated with greater severity of disease (Maunsell, Brisson & Deschenes, 1992; Schag,
Ganz, Polinsky, Fred, Hirji, & Peterson, 1993). Further, a patient’s phase of life has a
significant impact on adjustment: younger patients demonstrate greater levels of distress
than older patients (Simonton & Sherman, 1998; Vinokur, Threatt, Vinokur-Kaplan, &
Satariano, 1990). In breast cancer patients, advanced age has been associated with increased
social activities and contacts, with better mental health, perceived quality of life, and

functioning (Vinokur et al., 1989).
The literature indicates that the strongest concerns for women with early-stage breast
cancer are those relating directly to cancer as a health and life threat, the most salient
being the possibility of recurrence (Spencer et al., 1999). The experience of breast cancer
often forces women to confront fear and uncertainty, and most overwhelming, the idea of
their own mortality. These issues bring up many existential questions, for example “What
is important in my life?” and “What meaning does my life have?”
Other high-rated concerns include sickness and potential damage from undergoing
adjuvant therapies, pain, and premature death. Concerns regarding personal relationships
include “not being able to live out important relationships, . . . having life with a partner
cut short” (Spencer et al., 1999). Women with children often struggle with the following
questions, “What should I tell them?” “Do I have the resources to fight this disease and to
continue to parent my children at the same time?” “How will this effect their growth and
development?” “What will happen to them if I die?” (Oktay, 1998, p. 7).
Breast cancer also elicits concerns regarding a woman’s view of herself. Many treat-
ments for cancer challenge a woman’s body image and sexuality (Oktay, 1998). “The
systemic treatment of breast cancer with chemotherapy or hormonal therapy may also
affect self-image, fertility, and libido—all important components of ‘femininity’” (p. 6).
The combined effects of breast surgery, loss of hair, decreased libido, and early meno-
pause constitute a serious threat to a woman’s self-image. In addition, as the rate of breast
cancer has increased in younger women, issues of femininity arising from the impact of
disease on fertility are increasingly important (Oktay, 1998).
The experience of breast cancer can also create challenges for a marriage or signif-
icant relationship. Difficulties include communication problems, difficulty coping and
sexual dysfunction (one study found that approximately 50% of women with cancer had
at least one diagnosed sexual dysfunction during the posttreatment year) (Anderson,Ander-
son, & DeProsse, 1989). However, research suggests that when marriages are strong
before the development of breast cancer, the disease does not usually disrupt the relation-
ship, and may result in an even closer relationship (Oktay & Walter, 1991). And yet, in a
troubled relationship, the disease may prove too stressful for the couple to handle (Oktay,

1998).
Further, it is crucial not to overlook the importance of a caring husband or partner, as
support from the woman’s husband is usually ranked the most important (Holland &
Rowland, 1991). Marital quality has been identified as a critical contributor to quality of
life in women with breast cancer (Zahlis & Shands, 1991).
Positive Psychological Consequences
It has been suggested that the field of psychosocial oncology has focused on pathological
outcomes in response to cancer and has been insufficiently sensitive to the possibilities
for personal growth and transformation. For example,Andrykowski and colleagues (1993)
Quality of Life and Breast Cancer
503
propose that cancer should not be viewed as a stressor with uniformly negative outcomes,
but rather as a transitional event, which creates the potential for both positive and nega-
tive outcomes. Studies of psychosocial adjustment in individuals with a history of cancer
have largely focused upon assessment of negative psychosocial sequelae (Schag & Hein-
rich, 1989; Watson et al., 1991). Recently, however, a shift has occurred that is beginning
to explore the potential for positive sequelae (Andrykowski, Brady, & Hunt, 1993).
The current literature suggests that approximately half to two thirds of those diag-
nosed with breast cancer handle it well psychologically (Baker, Marcellus, Zabora, Pol-
land, Jodrey, 1997; Spiegel, 1996). In fact, some individuals with a history of cancer
report renewed vigor in their approach to life, and stronger interpersonal relationships
(Anderson, 1986; Cella & Tross, 1986). For example, Tempelaar and colleagues (1989)
found that cancer patients reported more positive and fewer negative social experiences
than a comparison group of healthy “normals.” Further, Collins and colleagues (1990)
interviewed 55 cancer patients who were within five years of the initial diagnosis or
cancer recurrence and found widespread reports of significant positive changes in per-
sonal relationships as well as in views of the self and in life priorities.
In a study of potential bone marrow transplant recipients, patients reported an improved
outlook on life, enhanced relationships, and greater satisfaction with religious concerns
(Andrykowski et al., 1993). The authors note that cancer should not be viewed as a homo-

geneously negative event, but as a “psychosocial transition, i.e. an event with significant
negative implications that can nevertheless cause individuals to restructure their attitudes,
values, and behaviors, and thus can serve to trigger positive psychosocial change” (p. 274).
It is important to note that these findings should not obscure the fact that the expe-
rience of breast cancer remains a major stressor (Carver et al., 1993). And yet, psycho-
social cancer research could benefit from adopting a more inclusive conceptualization of
the psychosocial impact of cancer. Both research and clinical work with cancer patients
should reflect the twin goals of minimization of distress as well as fostering positive
psychological, behavioral, and interpersonal change.
Relationship of Psychosocial Variables to Cancer
The experience of cancer is different for each individual. Research, however, suggests
that specific psychosocial factors play a role in disease onset and progression as well as
psychological adjustment. Below, we briefly highlight some of the important variables.
Control. Research suggests that an organism’s perception of control during stressful
events is very important to both psychological and physical health. For example, cancer-
ous tumor growth has been found to be enhanced in rats exposed to inescapable shock
compared to tumor growth in rats given escapable shocks (Sklar & Anisman 1979; Vis-
intainer, Volpicelli, & Seligman, 1982). Several studies have shown that increasing indi-
viduals’senseof control can have profound health implications. Rodin and Langer (1977)
found that nursing home patients given control over their schedule of activities lived
considerably longer than a matched comparison group.
The diagnosis of breast cancer can elicit feelings of helplessness and loss of control
(Anderson, Kiecolt-Glaser, & Glaser, 1994; Peterson & Stunkard, 1989). Recent research
suggests that responding to breast cancer with feelings of helplessness/hopelessness
increases risk of relapse and death (Watson, Haviland, Greer, Davidson, & Bliss, 1999).
This has been supported by earlier studies finding that feelings of loss of control in
response to breast cancer is a significant predictor of first recurrence and death from the
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Journal of Clinical Psychology, April 2001
disease (Pettingale, Morris, Greer, & Haybittle, 1985), and that having a helpless attitude

toward the disease is related to poor prognosis (Antoni & Goodkin, 1988; DiClemente &
Temoshok, 1985; Jensen, 1987; Pettingale et al., 1985). In addition, loss of control is
associated with increased anxiety and depression (Derogatis et al., 1983; Greer & Silber-
farb, 1982; Meyerowitz, 1983). On the other hand, maintaining a positive sense of control
in the face of breast cancer was significantly related to adaptation at six-month follow-up
(Ell, Nishimoto, Morvay, Mantell, & Hamovitch, 1989).
Given the substantial findings in the area of control and cancer, it is important to
explore the construct of control in greater depth. It has been argued (Shapiro, Schwartz,
& Astin, 1996) that the relationship between control and health is not a simple linear one:
“control is good, and the more control one has the better.” Acceptance (positive yielding)
is a unique feature of control that is often overlooked in Western psychology (Shapiro &
Astin, 1998), and yet, the literature demonstrates that acceptance is a crucial component
in gaining an optimal sense of control. For example, Astin and colleagues (1999) found
that women with breast cancer using a balanced mode of control including both assert-
iveness and acceptance showed the best psychosocial adjustment. Further, Carver and
colleagues (1993) found that acceptance was significantly linked to lower levels of dis-
tress in women with early-stage breast cancer. The authors suggest that “ultimately the
accommodating side may prove to be fully as important, or even more important . . . [as
the] active striving side” (p. 387).
Stress. Stress has been shown to have deleterious effects on one’s physical and men-
tal well-being (McCabe & Schneiderman, 1985; Selye, 1976). Stress has been associated
with increases of depression, anxiety, and psychological distress ( DeLongis, Folkman, &
Lazurus, 1988;Kanner,Coyne,Schaefer, & Lazurus,1981).Further, stresshasbeenshown
to negativelyeffect physical health.Forexample,throughtheuse ofviralchallengestudies
where patients are purposely exposed to various viral agents (such as the common cold),
Cohen and colleagues found that patients who report being under stress are more likely to
develop a clinical cold than those under low stress (Cohen, Tyrell, & Smith, 1991). Spe-
cifically related to cancer, a meta-analysis of psychosocial variables related to breast
cancer found significant effect sizes for an association between development of breast
cancer and reported stressful life events (McKenna et al., 1999). Further, in a study of

116 postsurgical breast cancer patients, Andersen and colleagues (1989) found that stress
levels significantly modulated immune parameters that involve NK cell activity.
Repression/Denial. In a meta-analytic review of the literature of psychosocial fac-
tors and the development of breast cancer, McKenna and colleagues (1999) found sig-
nificant effect sizes for an association between breast cancer and the use of a coping
strategy based on denial/repression.
Astudy by Jensen (1983) provides important evidence supporting the idea that repres-
sion involves disregulation of the immune system that, in turn, influences cancer. In a
prospective study of women with breast cancer, Jensen found that at follow-up subjects
with a repressive coping style and reduced levels of self-reported negative emotions had
poorer outcomes (including death) than those who did not meet this profile. Specifically,
Jensen demonstrated that repression of negative emotions is associated with an aggra-
vated course of breast cancer. It is important to highlight that the psychological variables
were two times more effective at predicting clinical outcomes than were the biological
indicators assessed.
Carver and colleagues (1993) found that overt denial was consistently related to
higher levels of concurrent distress. Further, denial predicted distress prospectively at the
Quality of Life and Breast Cancer
505
six-month follow-up. Stanton and Snider (1993) found that cognitive avoidance/ denial
was detrimental to women with breast cancer prebiopsy, postbiopsy, and at follow-up.
Their findings demonstrated that denial was an important predictor of high distress and
low vigor. They concluded “avoidance, even over a brief period, may be maladaptive
when the stressor is severe and potentially chronic” (p. 22).
The relationship between repression/ denial and cancer remains tentative and sweep-
ing conclusions are not justified, however, the potential importance of repressive coping
requires further investigation.
Emotional Expression. Emotional expression, sometimes considered the antithesis
of repression, is the ability to acknowledge and express emotions. The literature demon-
strates a positive association between emotional expression and health (Pennebaker, 1989;

Pennebaker & Beall, 1986). Findings indicate that emotional expression of negative and
traumatic events has a salutary influence on immune functions and resistance to illness.
For example, in experimental studies, subjects who wrote their deepest thoughts and
feelings about past traumas experienced enhanced T-cell responsivity (Pennebaker, Kiecolt-
Glaser, Glaser, 1988) and improved overall health (Pennebaker, 1989; Pennebaker, &
Beall, 1986) compared with control subjects who wrote about trivial events. Further,
Temoshok (1985) found correlations between emotional expression and levels of tumor-
infiltrating lymphocytes in melonoma patients. This research supports the hypothesis that
health is facilitated not simply by “good” emotions, but by the expression of all emotions.
Social Support. Higher levels of social support have predicted significantly longer
survival in several studies with localized or regional breast cancer (Cassileth et al., 1985;
Funch, Marshall 1983; Reynolds & Kaplan, 1990; Spiegle, Bloom, Kraemer, & Gottheil,
1989). Further, emotional support has been consistently associated with better quality of
life (Hegelsons & Cohen, 1996). The absence of a social support network has been tied to
a higher incidence of cancer (Thomas & Duszynski, 1974) a more rapid course of illness
(Reynolds & Kaplan, 1990), and increased depression (Woods & Earp, 1978). Aprospec-
tive study examining the effects of social context on rate of survival from breast cancer
found that women with increased support, particularly outside the home, had signifi-
cantly higher rates of survival at a four year follow-up (Waxler-Morrison, Hislop, Mears,
& Kan, 1991).
Despite the significance of social support to both psychological and physical well-
being, Peters-Golden (1982) found that only 52% of breast cancer patients reported receiv-
ing adequate amounts of support. Clearly, social support is a psychosocial variable deserving
attention.
Spirituality. Finally, spirituality may be another important variable in a cancer patient’s
experience. Spirituality may buffer against the negative effects of life stressors. It has
been demonstrated that spirituality can enhance physical and psychological well-being
(Oxman, Freeman, & Manheimer, 1995), and predicts various health outcomes (Levin,
1994). In fact, Levin (1994) reviews more than 250 published empirical studies on the
largely beneficial health effects of religious or spiritual practice. Because women with

breast cancer face many stressors, it appears important to address their spiritual as well
their cognitive, behavioral, and emotional needs in an attempt to buffer against the effects
of stress.
In a review of over 200 studies, religious commitment was correlated with improved
physical and functional status, reduced extent of psychopathology, greater emotional
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Journal of Clinical Psychology, April 2001
well-being, improved coping, and strengthened social support (Matthews, Larson, &
Barry, 1993; Matthews & Larson, 1995). Overall, these studies show that religious/
spiritual beliefs typically play a positive role in adjustment and optimal health (Fitchett,
Peterman, & Cella, 1996; Larson & Greenwold-Milano, 1995; Matthews, 1997). Further,
several studies have found that spiritual factors influence health status variables, such as
improved recovery and pain levels (Oxman et al., 1995; Pressman, Lyons, Larson, &
Strain, 1990; Yates, Chelmer, James, Follansbee, & McKegney, 1981).
Methodological Limitations
Although the psychosocial oncology literature is strong, substantial limitations and
unanswered questions remain. Much of the research has focused on heterogeneous
samples of patients who vary widely across disease site (e.g., melanoma vs. breast
cancer), stage of progression (e.g., localized vs. metastatic), and phase of illness (e.g.,
initial diagnosis vs. long-term survival). The challenges patients face vary widely across
these dimensions, and therefore, it is crucial for research designs to take this into
consideration.
Another limitation of the literature is that minorities have been dramatically under-
represented in psycho-oncology research (Anderson, 1992). Further, although the research
demonstrates the importance of the spousal relationship during the cancer experience,
there is a lack of controlled research concerning couples or family interventions. Finally,
a crucial question that remains unanswered is determining what these findings mean in
terms of clinical intervention and care. It is yet unclear if precise psychosocial factors can
be manipulated to effect quality of life and disease outcome. Despite these limitations,
the current literature holds important clinical implications for the field that will be dis-

cussed later in the article.
Psychosocial Interventions
Although specific causal pathways are yet unclear, the literature does document the psy-
chological and physiological benefit of numerous psychosocial interventions that have
been employed to help persons with cancer cope with the stress of the disease (Simonton
& Sherman, 1998). These include psychosocial support (Andersen, 1992); group psycho-
therapy (Spiegel & Bloom, 1983; Telch & Telch, 1986); self-help/self-care promotion
(Braden, Mishel, & Longman, 1998); and, hypnosis, imagery and relaxation (Fawzy
et al, 1993; Gruber et al, 1993; Post-White, 1993; Spiegel & Bloom, 1983; Walker et al.,
1999). Evidence from multiple studies suggests these psychosocial interventions can
improve mood (Cain, Kohorn, Quinlan, Latimer, & Schwartz, 1986; Cunningham &
Tocco, 1989; Greer, Moorey, & Baruch, 992), physical functioning (Berglund, Boulund,
Gustafson, & Sjoden, 1994), perceived meaning in life (Johnson, 1982), self-efficacy
(Telch & Telch, 1986), and lessen illness-related difficulties (Berglund et al., 1994; Telch
& Telch, 1986) in heterogeneous samples of patients with cancer.
In a 1995 meta-analysis (Meyer & Mark, 1995) of 45 randomized trials examining
psychosocial interventions for adults with cancer, the authors concluded:
The cumulative evidence is sufficiently strong that it would be an inefficient use of research
resources to conduct more studies . . . to ask the simple question: Is there an effect of [these
psychosocial interventions] on the emotional adjustment, functional adjustment, and treatment-
and disease-related symptoms of cancer patients. (p. 106)
Quality of Life and Breast Cancer
507
Spiegel et al. (1989) conducted a prospective intervention study of patients with
metastatic breast cancer. Findings demonstrated that a weekly support group meeting for
one year enhanced patients’psychosocial functioning and reduced pain as compared to a
standard care treatment control group. Further, in a ten-year follow-up, the data reported
that survival was significantly different, with a mean of 36.3 months in the intervention
group compared with 18.9 months in the control group.
Another study, conducted by Fawzy and colleagues (1993) supported these findings.

Early-stage melanoma patients assigned to a six-week psychosocial intervention demon-
strated increases in coping skills, but no affect on negative mood states or immune func-
tion immediately postintervention. However, at six-month follow-up, the intervention
group had significantly decreased negative mood states, and increased NK cell number
and NK activity. Further, at a five-year follow-up, 91% of those in the intervention group
had survived as opposed to only 71% in the control group.
Johnson (1982), randomized 52 patients with newly diagnosed or recurrent cancer to
either a psycho-educational group intervention “I Can Cope” or a control group. The
intervention group demonstrated decreased anxiety and increased perceived purpose and
meaning in life compared to the control group.
Berglund et al. (1994) performed a prospective randomized study with 98 cancer
patients who participated in a rehabilitation program focused on “starting again,” and
101 patients who served as controls. Subjects in the intervention improved significantly
in physical training, physical strength, fighting spirit, body image, and sleep when com-
pared with control participants.
Telch and Telch (1986) randomized 41 cancer patients with different diagnoses and
stages of disease to a coping skills instruction group, an emotional support group or a
no-treatment control group. The coping skills group showed consistent improvement
in affective state, cognitive distress, communications, coping with medical procedures,
and satisfaction related to work, social activities, physical appearance, sexual inti-
macy, physical and social activities. Patients in the emotional support group showed
little or no improvement, while the control patients actually deteriorated in psychological
functioning.
In a similar study, Cunningham and Tocco (1989), randomly assigned 60 cancer
patients with mixed diagnoses to one of two group treatments: a support group which
included coping skills training (psychoeducational), or a support group alone. In this
study, both intervention groups showed a significant improvement in affective state com-
pared with the no-treatment control group. The psychoeducational group, however, dem-
onstrated a greater gain, supporting the above findings of Telch and Telch.
Despite these promising findings, additional exploration is needed to confirm whether

psychosocial approaches can contribute to improved disease outcome, and to determine
the underlying mechanisms. Further, it is yet unclear if immunological changes generated
by psychosocial interventions are sufficiently robust to alter clinical status. Ultimately,
interventions should target specific psychosocial variables that have been proven to play
a role in both quality of life and perhaps even survival.
Introduction to Current NCI Study
The current study is part of a larger ongoing psychosocial intervention study funded by
the NCI. The focus of this component of the study was to develop a preliminary picture
of women with early-stage breast cancer within two years posttreatment. Correlations
between quality of life and psychosocial variables are explored. Further, we examine the
importance of the psychological construct of control for women with breast cancer.
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Journal of Clinical Psychology, April 2001
Methods
Participants
The sample consisted of 63 women diagnosed with stage II breast cancer who were
currently cancer free. Patients were recruited for a larger on-going project comparing a
structured stress-reduction intervention to an unstructured stress-reduction group (the
control). Inclusion criteria required that patients be female, between 18–75, fluent in
English, have a history of stage II breast cancer, currently cancer free, and within two
years posttreatment.
1
Justification for Stage of Cancer. This study focused on women with stage II breast
cancer. Although not the most advanced stage of disease, women with stage II breast
cancer experience a great deal of distress due to their diagnosis, treatment, and the fear of
breast cancer recurrence or metastases. The literature documents that women with stage
II breast cancer may suffer from feelings of anxiety, depression, difficulty sleeping, feel-
ings of hopelessness, and loss of control. In addition, by restricting the study to a some-
what homogeneous sample, the number of confounding variables is reduced and the
results are more easily interpreted.

Justification for Phase of Treatment. Although breast cancer can cause distress at
any moment after diagnosis, there appear to be peak periods throughout the patient’s
experience. Data indicate that the cancer diagnostic period is one of acute distress (Ander-
son et al., 1989), yet as many as one-third of patients with newly diagnosed breast cancer
continue to experience considerable psychological morbidity in the first two years after
initial treatment (Barber, 1978; Blalock, 1972).
Participants were recruited from the practices of all medical oncologists in the Tuc-
son community. Approximately 30% of the women who met eligibility criteria agreed to
participate in the study. The participants ranged in number of months post-treatment from
2 to 25 (mean ϭ 13.4, SD ϭ 6.9). The women ranged in age from 38 to 77 (mean ϭ 57,
SD 9.7). Forty-seven women were married or in an equivalent relationship, three were
divorced, four widowed, and nine single. Women on average had two children, ranging
from zero to six children. Fifty-four of the women were non-Hispanic white, five His-
panic, and two African American. Twelve women had completed graduate school, 19
were college graduates, 31 high school graduates. Thirteen women worked part time, 22
full-time, 19 were retired, and 9 were on disability.
Self-Report Measures
All participants completed a battery of questionnaires including measures of quality of
life, spiritual experience, psychological distress, sense of control, openness to experi-
ence, anxiety, depression, sense of coherence, marital quality, and worry.
Emotional Well-Being. Profile of Mood States Scale (McNair, Lorr, & Droppleman,
1981): a 65-item Likert intensity rating of mood descriptors generating six subscale scores
on depression, tension–anxiety, anger–hostility, confusion, vigor, fatigue. Reliability is
reported at .9.
1
A one-month flex period was allowed for the eligibility criteria. One participant greater than 24 months
posttreatment was included (25 months posttreatment).
Quality of Life and Breast Cancer
509
Depression. Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, &

Erbaugh, 1961) is a widely-used 21-item self-report measure that can serve as a quanti-
tative index of the severity of depressive symptoms during the past week.
General Worry. Penn State Worry Questionnaire (Meyer, Miller, Metzger, & Bork-
ovec, 1990). This 26-Item inventory is Likert scale, and assesses the trait of worry. It has
been found to be psychometrically sound with good validity, reliability, and internal
consistency.
State and Trait Anxiety. The State-Trait Anxiety Inventory (Form Y)—STAI Form 1
(Spielberger, Gorsuch, & Lushene, 1970) 40-item self-report instrument was used to
measure both state and trait anxiety using a 1–4 Likert rating scale.
Spirituality. The Index of Core Spiritual Experiences—INSPIRIT, developed by Kass
and colleagues (1991), is a seven-item scale designed to assess two characteristic ele-
ments of core spiritual experiences: (1) “a distinct event and a cognitive appraisal of that
event which resulted in a personal conviction of God’s existence (or of some form of
Higher Power as defined by the person)”; and (2) “the perception of a highly internalized
relationship between God (Spiritual core) and the person.” Scores calculated for this
measure range from 1–4 (with higher scores reflecting a greater number of spiritual
experiences). This instrument demonstrates high internal reliability, Kass and colleagues
(1991) report an alpha coefficient of .9.
Quality of Life. The Functional Assessment of Cancer Treatment-Breast (FACIT-B)
(Brady et al., 1997) consists of 36 items for evaluating functional impairment and the
perceived effect of that impairment on quality of life. It is self-administered and ranked
on a five point Likert scale. The FACIT-B is comprised of five areas of quality of life:
physical well being, social/family well-being, emotional well-being, and functional well-
being, and nine additional items specifically related to breast cancer. The nine breast
cancer–specific items include questions related to appearance, sexuality, treatment side
effects, and stress/illness. The measure is reliable, and reports a Cronbach’s coefficient
alpha of .9.
Control. Shapiro Control Inventory (SCI) (Shapiro, 1992): this 187-item instrument
was adapted for the present study to assess one’s mode of control describing individual’s
characteristic cognitive/behavioral style of responding to control related issues along

four different quadrants: positive assertive, positive yielding (acceptance), negative assert-
ive, negative yielding. Studies show that the internal reliability of these subscale range
from .70 to .89; test–retest reliability ranges from .67 to .93.
Marital Quality Scale. (Hendrick, 1998) Hendrick’s Relationship Assessment Scale,
is a self-report measure consisting of 7 questions to assess relationship satisfaction and
quality. The scale reports good internal consistency (alpha ϭ .86).
Sense of Coherence. (Antonovsky, 1987) A 29-item scale with high reliability and
validity measuring the construct of sense of coherence consisting of comprehensibility,
manageability and meaningfulness.
Procedure
If eligible, women came to the Arizona Cancer Center for an initial intake interview with
the research associate.As part of the larger ongoing study, the nature of the study and the
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Journal of Clinical Psychology, April 2001
process of randomization were explained to the participants and informed consent was
obtained. Using an open-label study design, participants were then randomized into the
experimental or the control group. Two weeks prior to the beginning of the intervention,
participants completed a set of psychosocial questionnaires.
Results
What follows are the results from the preliminary analyses conducted as part of the larger
project.
Quality of Life and Psychosocial Variables
See Table 1.
Control and Psychosocial Variables
Positive Assertive and Positive Yielding. The positive assertive mode of control was
positively correlated with sense of coherence (r ϭ .55, p Ͻ .001), vigor (r ϭ .42, p ϭ
.001), and total quality of life (r ϭ .44, p Ͻ .001). This mode of control was negatively
correlated to depression (r ϭϪ.34, p ϭ .007), anger and hostility (r ϭϪ.27, p ϭ .035),
fatigue (r ϭϪ.26, p ϭ .046), confusion (r ϭϪ.44, p Ͻ .001), tension (r ϭϪ.37, p ϭ
.003), and state and trait anxiety (r ϭϪ.42, p ϭ .001). The positive yielding mode of

control was positively correlated with sense of coherence (r ϭ 41, pϭ .001), total quality
of life (r ϭ .35, pϭ .006), and vigor (r ϭ .28, pϭ .027). It was negatively correlated with
trait anxiety (r ϭϪ.33, p ϭ .008).
Table 1
Correlation Matrix of Quality of Life and Psychosocial Variables
Total
QOL
Physical
QOL
Social
QOL
Emotional
QOL
Functional
QOL
Breast Cancer
QOL
Marital quality .32* Ϫ.001 .5** .04 .16 .37*
Sense of coherence .7** .34** .7** .49** .6** .47**
Vigor .6** .6** .33** .51** .66** .32**
Spirituality .13 .10 .03 .24 .18 .03
Positive assertive control .44** .16 .43** .31* .44* .27*
Positive yielding control .35** .09 .38** .43** .36** .08
Negative assertive control .01 Ϫ.02 .06 .004 .07 Ϫ.07
Negative yielding control Ϫ.12 .11 Ϫ.27* Ϫ.09 Ϫ.13 Ϫ.12
Anger/hostility Ϫ.63** Ϫ.35** Ϫ.58** Ϫ.42** Ϫ.47** Ϫ.5**
State anxiety Ϫ.7** Ϫ.45** Ϫ.63** Ϫ.7** Ϫ.64** Ϫ.34**
Trait anxiety Ϫ.7** Ϫ.46** Ϫ.50** Ϫ.7** Ϫ.64** Ϫ.46**
Depression Ϫ.77** Ϫ.57** Ϫ.53** Ϫ.59** Ϫ.73** Ϫ.51**
Fatigue Ϫ.49** Ϫ.56** Ϫ.36* Ϫ.33* Ϫ.33* Ϫ.4**

Confusion Ϫ.58** Ϫ.38** Ϫ.41** Ϫ.48** Ϫ.41** Ϫ.41**
Tension Ϫ.7** Ϫ.52** Ϫ.54** Ϫ.6** Ϫ.5** Ϫ.5**
Emotional distress Ϫ.48** Ϫ.48** Ϫ.57** Ϫ.41** Ϫ.37** Ϫ.49**
Worry Ϫ.6** Ϫ.48** Ϫ.40** Ϫ.49** Ϫ.54** Ϫ.38**
*p Ͻ .05.
**p Ͻ .01.
Quality of Life and Breast Cancer
511
Negative Assertive and Negative Yielding. The negative assertive mode of control
was positively correlated with vigor (r ϭ 26, p ϭ .04). The negative yielding mode of
control was significantly correlated with total emotional distress (r ϭ .32, p ϭ .013), and
negatively correlated with social quality of life (r ϭϪ.27, p ϭ .04).
Discussion
This study focused on quality of life for women with stage II breast cancer within two
years posttreatment. The data presented are the first look at data from a larger on-going
project. Therefore, although the findings are interesting, it is important to emphasize that
they are not the final statement. Within this context, we discuss the results of our prelim-
inary analyses.
Quality of life was correlated with psychosocial variables. Greater quality of life was
significantly correlated with sense of coherence, marital quality, vigor, and the two pos-
itive modes of control. Lower quality of life was correlated with greater amounts of
depression, anxiety, anger and hostility, and general emotional distress. These findings
support the hypothesis that psychosocial variables are related to achieving optimal qual-
ity of life (Cotton, Levine, Fitzpatrick, Dold, & Targ, 1999). However, as the findings are
correlational, it is essential not to imply causation.
Future clinical intervention studies are needed to determine if specific psychosocial
variables have an impact on quality of life. For example, support groups are widely
practiced; however, rarely are psychosocial variables such as sense of control explicitly
targeted. It would be important to determine if targeting this variable significantly effected
outcome.

Another interesting finding was that greater use of the two positive modes of control
was associated with greater quality of life and emotional well being. Positive assertive
control was related to greater sense of coherence, vigor, and overall quality of life as well
as lower depression, anger and anxiety. Positive yielding (acceptance) was related to
greater sense of coherence, vigor, and overall quality of life as well as lower anxiety. This
is consistent with Cotton and colleague’s (1999) finding that quality of life was related to
a measure of acceptance similar to the positive yielding mode of control.
Further, higher use of the negative yielding mode of control (hopelessness/
helplessness) was significantly related to greater emotional distress, suggesting that pas-
sively resigning or giving up may increase distress levels. This finding is consistent with
the literature that breast cancer patients who exhibit helplessness and resignation have an
increased risk of psychological distress (Shapiro et al., 1997) and even relapse and death
(Watson, Haviland, Greer, Davidson, & Bliss, 1999). Contrary to our hypothesis, the
negative assertive mode of control was positively correlated with vigor. This may suggest
that in some cases a negative assertive mode of control may be adaptive, especially in
increasing energy and defeating helplessness.
The preliminary findings of this study contribute to the literature by examining qual-
ity of life in conjunction with important psychosocial variables (sense of control, psy-
chological distress, and sense of coherence) in a homogeneous sample of women (early
stage breast cancer within two years posttreatment). A strength of the study is the homo-
geneity of the sample of women. Through conducting research with a select sample of
women with the same stage of breast cancer and the same phase of treatment, the vari-
ance that might be evidenced in a more heterogeneous sample is reduced. Further, the
study confirms the existing literature that quality of life is significantly related to psy-
chosocial variables, reinforcing the need for future research to examine the specific inde-
pendent effects of targeting psychosocial variables (e.g., sense of coherence, sense of
512
Journal of Clinical Psychology, April 2001
control) in clinical interventions. Finally, although the construct of control has been
addressed in other studies, this study is unique in that it looks at both the assertive/

change mode of control as well as the less studied accepting/letting go mode of control.
On the other hand, it is crucial to emphasize the preliminary and tentative nature of
these findings. Further, our small, homogeneous sample does restrict the generalizability
of our study to other stages of breast cancer and other phases of treatment as well as to
people with other cancers or illnesses. In addition, our sample included women who were
primarily Caucasian from a single geographic area, which also restricts the applicability
of these findings to other populations.
Further, a large number of measures were used compared to the relatively small
number of subjects. Given that these measures were all self-report, there is a possibility
of considerable overlap and intercorrelation among them. Therefore, individual correla-
tions with quality of life must be viewed as more exploratory than definitive. Analyses
that employ procedures such as factor analysis and structural equations modeling, will be
useful in exploring the direct and indirect relationships among these variables.
Clinical Implications
There are several directions in which the field of psychosocial oncology should continue.
It appears crucial that health care professionals provide patients with avenues for dealing
with intrapersonal issues (e.g., sexuality), interpersonal issues (e.g., family relation-
ships), and existential issues (e.g., confronting issues of mortality). Further, interventions
should attempt not only to reduce psychological distress, but also to enhance partici-
pants’ potential for growth and transformation as suggested by the positive psychology
literature (Andrykowski et al., 1993). Finally, building upon the literature indicating a
strong association between psychosocial variables and disease outcome/adjustment, spe-
cial consideration should be directed toward specific variables such as sense of control,
stress, repression, emotional expression, and social support.
It is promising that potentially malleable psychosocial variables (e.g., sense of con-
trol, emotional expression) are correlated with quality of life in women with breast can-
cer. However, to date, the majority of the findings are correlational, thereby limiting firm
conclusions. For example, it is impossible to determine from our data if perceptions of
control increase quality of life, or if perceptions of control stem from current quality of
life and adjustment.

And yet, it is indisputable that a relationship exists between psychosocial variables
and quality of life in women with breast cancer. This suggests the necessity of clinical
intervention studies aimed at increasing adaptive variables (e.g., sense of coherence,
acceptance) and decreasing maladaptive ones (e.g., depression, denial) to determine if
changing these variables can affect quality of life. The literature needs more rigorously
designed studies to provide accurate data about health-promoting psychological pro-
cesses, thereby developing a strong scientific basis for future intervention.
Conclusion
Considerable advances have been made in our understanding of the nature and intensity
of the psychosocial challenges confronting women with breast cancer as they transition
through their illness. The literature demonstrates a relationship between quality of life
and psychosocial variables. Further, advances have been made linking psychosocial inter-
ventions to enhance psychological health, immune function, and even survival. We believe,
therefore, that one of the most salient factors involved in comprehensive care for women
Quality of Life and Breast Cancer
513
with breast cancer is acknowledging the significant role psychosocial variables may play
on both psychological and physiological well-being. This implies that health care profes-
sionals must recognize and take into consideration the importance of psychosocial vari-
ables and share this understanding with their patients.
Future research, amenable to statistical analyses such as path analysis and structural
equations modeling, is needed to determine precisely which psychosocial variables are
effective in promoting greater health. From this data more effective interventions that
address the whole person, including specific psychosocial variables, can be developed.
This transition to a more integrative and systemic approach to health is a critical shift
toward providing more humane and holistic care for breast cancer patients, and ulti-
mately for all patients.
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