Stress Responses and Worries of Women at Risk for Breast Cancer

Czarina E. Sánchez, Kate Berlin, & Bruce E. Compas Vanderbilt University

Abstract

Introduction

Method

Discussion and Conclusions

References

Hypothesis 1: Results did not offer a replication of Bovberg studies. General anxiety cannot be used as a predictor of biological stress levels for women at risk for breast cancer.

Hypothesis 2: Intrusive breast cancer thoughts were found to be positively correlated to increased cortisol stress levels. Avoidance of those thoughts was not. A reason is that intrusion could be considered an effect of shorter term. Since the IES asks about symptoms in the past 7 days, women may have been influenced to think about breast cancer because of their participation in the study. Because the intrusive thoughts about their risk for breast cancer had just begun, perhaps the participants in the current study were not yet so bothered by them to try to avoid them. The results also have implications for psychological treatments. The focus in any attempt to decrease stress levels, in women at risk for breast cancer, should be on breast cancer specific anxiety rather than general anxiety and worries.

Hypothesis 3: No relation between perceived risk and stress was found. Using a measure with more reliability would be an improvement to the design.An explanation for the lack of positive correlation is that perceived risk is not a measure of worry. A woman can believe she will develop breast cancer, but that does not mean she is worried about it. The indication of a negative relationship seen in the analysis could be due to women, who perceive their risk to higher, being more proactive in learning and dealing with their risk. In this way, they are less stressed dealing with the disease.

Hypothesis 4. No relation between behavioral and physiological anxiety was found. A reason might be that the women are not even realizing their own sensitivity to the topic of breast cancer so their stress was seen in their physiological response but not on their physical behavior. The significant correlation between whine/complain and cortisol levels was an unexpected finding which points to a very specific behavior and stress biology relationship.

Future studies could be improved in several ways. A larger sample would undoubtedly make the power of the analysis greater and the effects easier to recognize. Another way would be to have a breast cancer task along with a traditional laboratory stress task to elicit stronger stress responses. The discussion did not provide acute reactivity and therefore the progress of the stress response could not be assessed. By doing a combination, the effects of the breast cancer discussion and the biological reactions of an acute stressor could be better analyzed.

Gold, S.M., Zakowski, S. G., Valdimarsdottir, H.B., & Bovberg, D.H. (2003). Stronger endocrine responses after brief psychosocial stress in women at familial risk of breast cancer. Psychoneuroendocrinology, 28, 584-593

James, G.D., van Berge-Landry, H., Valdimarsdottir, H. B., Montgomery, G. H., & Bovberg, D. H. (2004). Urinary catecholamine levels in daily life are elevated in women at familial risk of breast cancer. Psychoneuroendocrinology, 29, 831-838.

Steward, D.E., Cheung, A.M., Duff, S., Wong, F., McQuestion, M., Cheung, T., et al. (2001). Attributions of cause and recurrence in long-term breast cancer survivors. Psych-Oncology, 10, 179-183.

Results

Correlational Analyses

Hypothesis 1: No significant relationship was found between general anxiety and biological stress levels

Hypothesis 2: A significant correlation was found between intrusion and cortisol levels (r= 0.49 to .57 with p< 0.01) at all five time points

Hypothesis 3: No significant correlation was found between perceived risk and biological stress levels. In fact, contrary to prediction, the relationship was inverse.

Hypothesis 4: No significant correlation was found between observed anxiety and avoidance behavior and biological stress levels.

Research Questions 1. What is the relationship between the mothers’

biological stress and their general level of anxiety? Hypothesis 1: Women who experience higher overall anxiety will also show an increased biological response because of an over activated stress response system.

2. What is the relationship between the mothers’ biological stress and breast cancer specific concern? Hypothesis 2: As seen in previous studies (Gold et al. 2003, James et al. 2004) women at increased risk for breast cancer have elevated responses to stressors. It is hypothesized that women with increased breast cancer concern will also have an increased stress response.

3. What is the relationship between the mothers’ biological stress response and their perceived breast cancer risk? Hypothesis 3: Women, who perceived their risk to be higher, will also have increased biological stress response.

4. What is the relationship between the mother’s biological stress and their observed anxiety and avoidance behavior during the breast cancer discussion? Hypothesis 4: Women who show more anxiety and/or avoidance during the interaction will also show an increased biological stress response.

Participants:

58 mothers ages 32 to 60 (M = 48) with their daughters ages 11-32 (M=19)Ethnic makeup of the sample:

71% white, 19% African American, 3% other, 7% did not respond

Only mothers’ data was used for this study

Measures:

Biological StressSalivary assays of cortisol and -amylase (as a

measure of nor epinephrine)

General AnxietyBeck Anxiety Inventory (BAI)

Intrusive and Avoidance thoughtsImpact of Event Scale (IES) with subscales:

AvoidanceIntrusion

Perceived RiskAssessment of risk question

How likely are you to develop breast cancer?

Observed Anxiety and Avoidance Iowa Family Interaction Rating Scales coding

system for video taped breast cancer interactionAnxiety- participant’s emotional distress conveyed as anxiety, nervousness, fear, tension, stress, worry, concern, and embarrassment in behavior Avoidance- extent to which the participant averts her gaze and/or orients her body away from the other person as to avoid interaction

Procedure:

QuestionnairesParticipants were asked to provide information

for the psychological measures previous to the lab visit

Laboratory visitMother and daughter were video taped as they

engaged in a 15 minute discussion on their thoughts and feelings about breast cancer. Salivary samples were drawn before the interaction and at four later time points

The relationship between stress and cancer development has not been firmly established. Large scale meta-analyses have found only a weak connection between the two. However, stress, especially in the minds of many women with breast cancer, seems to have a direct connection with the development of cancer. For example, stress was the most attributed cause of breast cancer in a survey of 400 women with the disease (Steward, Cheung, Duff, Wong, McQuestion, Cheung, et al., 2001). Because of the mixed findings in the literature with respect to the effect of psychological factors in the progression of breast cancer, it is imperative to seek out information to clarify the relationship

The chance for a woman in the United States of developing breast cancer during her lifetime is one in eight. Breast cancer is the most common cancer among women besides skin cancer (American Cancer Society, 2007). In 2007, an estimated 178,480 women in the United States will be diagnosed with invasive breast cancer.

Treatments for breast cancer range from surgery to chemotherapy and are accompanied by serious physical trials. However, it is not only the physical effects of breast cancer that have a dramatic influence on the women’s wellbeing. Cancer can also be accompanied by significant emotional toil. Depression and anxiety are often experienced by women faced with cancer (e.g., Epping-Jordan, Compas, & Howell, 1994). Another important psychological factor is the presence of intrusive thoughts, defined as unwanted images and strong waves of feelings in response to a specific stressor. Intrusive thoughts are characteristic of a post-traumatic stress response to a cancer diagnosis or the treatment of the disease. These uncontrollable worries are closely tied to unsuccessful efforts to avoid or suppress unwanted thoughts or images about the disease. The risk of developing breast cancer can function as a choric source of stress in women. Chronic stress has been linked to a decrease in health. For example, a decrease in immunocompetence puts women at an increased risk for infectious diseases.

The physiological impact of a breast cancer discussion between mothers and their daughters was analyzed in relation to other anxiety and concern measures. Fifty-eight mothers with varied breast cancer histories participated. Measures of general anxiety (BAI), concern about breast cancer (IES), perceived risk, and observational data were correlated to salivary cortisol and norepinephrine measured by alpha-amylase. Analysis revealed that cancer specific worries but not general anxiety were positively correlated to cortisol levels, specifically IES-intrusion subscale scores, but not IES-avoidance. Observed behavioral anxiety and avoidance during the interaction did not show significant correlations. However, exploratory analyses revealed whine/complain behavior to be positively correlated with cortisol levels.

Primary Objective:

The focus of the current research is to better understand the relationship between the psychological and biological stress of women at risk for breast cancer.

** correlation significant at p< 0.01