Title: Cancer deaths in the aged
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Permanent Link: http://ufdc.ufl.edu/UF00099582/00001
 Material Information
Title: Cancer deaths in the aged psychosocial and disease variables
Physical Description: ix, 215 leaves : ill. ; 28 cm.
Language: English
Creator: Cason, Laura Rose, 1954-
Publication Date: 1985
Copyright Date: 1985
 Subjects
Subject: Death -- Psychological aspects   ( lcsh )
Cancer -- Prognosis   ( lcsh )
Cancer -- Psychological aspects   ( lcsh )
Foundations of Education thesis Ph. D
Dissertations, Academic -- Foundations of Education -- UF
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Thesis: Thesis (Ph. D.)--University of Florida, 1985.
Bibliography: Bibliography: leaves 205-214.
General Note: Typescript.
General Note: Vita.
Statement of Responsibility: by Laura Rose Cason.
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Bibliographic ID: UF00099582
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 000873482
notis - AEH0787
oclc - 014589036

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CANCER DEATHS IN THE AGED:
PSYCHOSOCIAL AND DISEASE VARIABLES










By

LAURA ROSE CASON























A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

1985




















ACKNOWLEDGEMENTS

I wish to acknowledge the assistance of my doctoral

committee, Dr. Hannelore L. Wass, Dr. Walter A. Busby,

Dr. Stephen Olejnik, and Dr. Gordon F. Streib, in the

preparation of the dissertation, and in particular, am

grateful for the guidance and encouragement offered by Dr.

Wass, chairperson of the committee.

My indebtedness to the patients who participated in

this study and to their physicians, Dr. Terry Bloom, M.D.,

Dr. Walter Durkin, M.D., Dr. Gregory Favis, M.D., Dr.

Herbert Kerman, M.D., Dr. Tariq Siddiqui, M.D., and Dr.

Alvin Smith, M.D., is acknowledged. I am also appreciative

of the assistance of Dr. Kerman and Mrs. Rebecca McDonald,

R.N., in arranging for the research to be conducted at

Halifax Hospital Medical Center.

The assistance provided by Mrs. Margaret Elaine Free in

the preparation of the manuscript is gratefully acknowledged

and to my family and friends who encouraged me in this

endeavor, I extend my special thanks.










TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS . . . . . . .... .. .. ii

LIST OF TABLES . . . . . . . . . v

ABSTRACT . . . . . . . . ... . . viii

CHAPTERS

I INTRODUCTION . . . . . .. .. .. 1

Background of the Problem . . . . . 1
Statement of the Problem . . . . . 8
Research Questions . . . . . ... 10
Definition of Terms . . . . . .. 10

II REVIEW OF THE LITERATURE . . . . ... 14

Psychosocial Variables and the
Development of Cancer . . . . .. 15
Theoretical Concepts . . . . . .. 16
Research Findings . . . . . .. 20
Evaluation and Summary . . . . ... 27

Psychological Variables and the
Progression of Cancer . . . . . .. 31
Theoretical Concepts . . . . ... 32
Research Findings . . . . . ... 38
Evaluation and Summary . . . . .. 47

Social Support, Socioeconomic Status,
and the Progression of Disease . . . .. 50
Theoretical Concepts . . . . ... 50
Research Findings . . . . . .. 53
Evaluation and Summary . . . . ... 62

Concluding Remarks . . . . . . .. 66

III METHODS . . . . . . . . . 71

Introduction . . . . .. .. . . 71
Research Questions and Hypotheses . . .. 73
Design of the Study . . . . . .. 75
Part I: Determining Survival Expectations 76
Subjects . . . . . . . . . 76
Instruments . . . . . . . . 81
Procedure . . . . .. . . 81
Analysis . . . . . . . . . 84








Page

Part II: Psychosocial Analysis . . . .. 90
Subjects . . . . . . . . .. 90
Instruments . . . . . . . .. 93
Procedure . . . . . . . . .. 99
Analysis . . . . . . . . .. 100
Limitations . . . . . . . .. 109

IV RESULTS . . . . . . . .. .. 111

Introduction . . . . . . . . 111
Determining Survival Expectations . . .. .112
Lung Cancer . . . . . . . .. 112
Breast Cancer . . . . . . ... 119
Rectocolon Cancer . . . . . . .. .122
Psychosocial Analysis . . . . . .. .125
Psychosocial Variables and Survival ... .125
Disease Variables and Psychosocial Status . 138

V DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS. 147

Discussion . . . . . . . . .. 147
Determining Survival Expectations . . .. .147
Psychosocial Analysis . . . . ... .153
Conclusions . . . . . . . .. 165
Determining Survival Expectations . . .. .165
Psychosocial Analysis . . . . . .. .167
Recommendations . . . . . . . .. 171
Determining Survival Expectations . . .. .171
Psychosocial Analysis . . . . . .. .174

APPENDICES

A PSYCHOSOCIAL INTERVIEW . . . . ... .176

B INDEX OF VULNERABILITY . . . . . .. .178

C INDEX OF CO-MORBIDITY . . . . . ... 180

D CODE BOOK . . . . . . . ... 181

E PATIENT CONSENT FORM . . . . . ... .186

F DETERMINING SURVIVAL EXPECTATIONS:
COMPARISON OF GROUPS USED IN REGRESSION
ANALYSIS . . . . . . . ... 188

G MATRIX OF INTERCORRELATIONS:
INDEPENDENT AND DEPENDENT VARIABLES . . .. .201

REFERENCES . . . . . . . . . .. . 205

BIOGRAPHICAL SKETCH . . . . . . ... 215











LIST OF TABLES


Page

1. Age Distribution of Lung, Breast, and
Rectocolon Cancer Deaths: U.S.A., 1978 . . 77

2. Summary of Characteristics of the Sample . 79

3. Predicting Survival: Independent and
Dependent Variables . . . . . ... 84

4. Variables Tested in Two-Series Regression
Analysis: All Sites . . . . . ... 87

5. Regression Equations for Lung Cancer:
Independent and Dependent Variables . . .. 88

6. Regression Equations for Breast Cancer:
Independent and dependent Variables . . .. 89

7. Regression Equations for Rectocolon Cancer:
Independent and Dependent Variables . . .. 89

8. Development of the Sample for Psychosocial
Analysis . . . . . . . . ... .93

9. Independent Variables Drawn from Scales
of the Index of Vulnerability . . . .. 101

10. Independent Variables Developed from
Clusters of Vulnerability Scales . . ... 102

11. Independent Variables Drawn From Structural
Indices of Support . . . . . .. 103

12. Disease Characteristics Used as Independent
Variables . . . . . . . ... 107

13. Regression Analysis of the Main Effects of
Independent Variables for Lung Cancer . . 113

14. Regression Analysis of Lung Cancer Cases:
Model One . . . . . . . ... 117

15. Regression Analysis of the Main Effects of
Independent Variables for Breast Cancer . 120










Page
16. Regression Analysis of Breast Cancer Cases:
Model One . . . . . . . ... 121

17. Regression Analysis of the Main Effects of
Independent Variables for Rectocolon Cancer. 123

18. Regression Analysis of Rectocolon Cancer
Cases: Model Two . . . . . ... 124

19. Descriptive Statistics of the Scales of
the Index of Vulnerability . . . ... 127

20. Matrix of Intercorrelations for Cluster One. 128

21. Matrix of Intercorrelations for Cluster Two. 128

22. Matrix of Intercorrelations for Cluster Three. 129

23. Summary of Demographic and Regression Data
for the Three Sites . . . . . ... 131

24. Elements of the Survival Quotient: Lung
Cancer Cases . . . . . . . .. 132

25. Elements of the Survival Quotient: Breast
Cancer Cases . . . . . . ... 133

26. Elements of the Survival Quotient:
Rectocolon Cancer Cases . . . . .. 134

27. Values of the Pearson r for Indices of
Structural Support: Shorter Survival . . 137

28. Duration of the Illness Relative to the
Interview . . . . . . ... 140

29. Closeness to Death at the Time of the
Interview . . . . . . . ... 141

30. Correlations between Co-Morbidity and
Selected Psychosocial Variables . . .. 143

31. Correlations Between the Duration of the
Selected Psychosocial Variables . . .. 144

32. Correlations Between the Closeness to
Death and Selected Psychosocial Variables 145

33. Summary of Regression Data from Two Studies. 149

vi








Page

34. Psychosocial Variables and Survival
Expectations: Summary of Findings . . .. .156

35. Psychosocial Variables and the Duration
of Illness: Comparison of Correlation
Coefficients . . . . . . . ... 162

36. Psychosocial Variables and Closeness to
Death: Comparison of Correlation
Coefficients . . . . . . . ... 164

37. Comparison of Lung Cancer Cases: Age
and Survival . . . . . . . ... 188

38. Demographic Characteristics of Lung
Cancer Cases . . . . . . . ... 188

39. Disease Characteristics of Lung
Cancer Cases . . . . . . . ... 189

40. Initial Treatment of Lung Cancer Cases ... 190

41. Subsequent Treatment of Lung Cancer Cases . 191

42. Comparison of Breast Cancer Cases: Age
and Survival . . . . . . . ... 192

43. Demographic Characteristics of Breast
Cancer Cases . . . . . . . ... 192

44. Disease Characteristics of Breast Cancer
Cases . . . . . . . . ... .. . 193

45. Initial Treatment of Breast Cancer Cases . .. 194

46. Subsequent Treatment of Breast Cancer Cases. . 195

47. Comparison of Rectocolon Cancer Cases:
Age and Survival . . . . . . ... .196

48. Demographic Characteristics of Rectocolon
Cancer Cases . . . . . . . ... 196

49. Disease Characteristics of Rectocolon
Cancer Cases . . . . . . . ... 197

50. Initial Treatment of Rectocolon Cancer Cases 198

51. Subsequent Treatment of Rectocolon Cancer
Cases . . . . . . . . ... .. . 199

52. Matrix of Intercorrelations: Independent
and Dependent Variables . . . . ... .201
vii













Abstract of Dissertation Presented to the Graduate
School of the University of Florida in Partial Fulfillment
of the Requirements for the Degree of Doctor of Philosophy


CANCER DEATHS IN THE AGED:
PSYCHOSOCIAL AND DISEASE VARIABLES

By

Laura Rose Cason

August 1985

Chairperson: Hannelore L. Wass
Major Department: Foundations of Education

Relationships between psychosocial variables and the

survival of elderly cancer patients were explored. Thirty

patients, age 60 and above, with terminal cancer of the

lung, breast, or rectocolon were interviewed to elicit a

broad range of information regarding attitudes, moods,

social support, and socioeconomic status. Variability in

survival due to the effects of disease and medical variables

was controlled by using a value of relative survival in the

analysis that was based on a comparison of expected survival

and observed survival.

The survival expectations were determined through a

series of regression analyses of biological, medical, and

disease information on deceased cancer patients including

266 cases of lung cancer, 101 cases of breast cancer, and

166 cases of rectocolon cancer. The predictor variables

included in the exploratory analysis were age, sex, race,


viii











stage, histology, initial treatment, and subsequent treat-

ment. A small number of variables with predictive power

were selected for equations used to predict the survival of

the 30 patients in the sample.

The psychosocial analysis involved a series of corre-

lation analyses in which psychosocial variables were first

compared to survival. The relationships between three addi-

tional disease variables and psychosocial status were also

explored. These variables included the degree of co-morbidi-

ty, the duration of the illness, and the closeness to death.

The results indicate that variability in survival from

cancer is largely related to the primary site of the cancer,

the stage of the disease, and the treatment given. The

findings do not provide evidence of a relationship between

psychosocial variables and the survival of elderly patients

with terminal cancer. However, a relationship between

certain disease variables and psychosocial status is

suggested. Higher levels of turmoil were experienced by

patients with less co-morbidity. Greater denial was

associated with a more recent diagnosis. And, although the

relationships were not significant at the .05 level, higher

values on all indices of psychological vulnerability were

associated with being closer to death. This pattern of

relationships suggests that psychosocial status is related

to the degree of the illness. A series of 15 recommenda-

tions were offered for further study.
ix













CHAPTER I
INTRODUCTION


Background of the Problem


The diagnosis of cancer precipitates a period of

uncertainty in the life of the patient and family. And,

although the uncertainty of the future underlies this

experience, for most people the more immediate questions

demand considerable attention. These questions are related

to what has caused the disease and what will bring about a

cure. These are the questions that are asked of physicians

and others involved in medical care. And, with few

exceptions, these are questions for which there are no

simple or clear answers.

Although there is a great deal that is not understood

about the causes of cancer and the reasons for the

progression of the disease, medical research has revealed

important findings about cancer and cancer treatment. These

findings suggest that there are many causative factors in

the development of cancer. Environmental factors have been

identified as major determinants in most of the cancers that

affect humans (Bryan, 1983). The findings also suggest that

certain characteristics of the cancer cell are important

predictors of how, and how quickly, the disease will

progress (Haller & Glick, 1983).
1












However, in addition to the concepts advanced through

traditional medical research, concepts regarding the effect

of mental states on the development of cancer and on a cure

for cancer are prevalent in our culture. Various concepts

of this kind are revealed in the explanations that many

cancer patients give for their disease. Certain personality

characteristics, conflicts, stress, and loss are suggested

as possible explanations for a diagnosis that cannot be

conclusively explained by the medical profession. Similar

concepts are often central to the beliefs that patients and

their families have regarding their recovery or cure from

cancer. The willingness to fight the disease, the ability

to keep a positive attitude, and the will to live are

believed to affect survival from cancer.

Is there a basis for the belief that mental states are

related to the development or progression of cancer? This

was the fundamental question of this research. The

methodology and findings of studies that have explored this

relationship provided the background for the approach taken

to the problem.

The relationship between mental states and cancer has

been studied through two different approaches. One approach

has focused on the relationship between certain mental

states and the development of cancer. The other approach











has studied the effect of mental states on the progression

of disease, and ultimately on survival. Many psychosocial

variables have been identified for study.

The role of psychosocial variables in the development

of cancer has been the object of many reports in the

professional literature. Several variables are repeatedly

noted in these reports as being characteristic of persons

who develop cancer. They include loss of a significant

relationship, major life change, depression, hopelessness,

and restricted hostile or aggressive expression (Bahnson &

Bahnson, 1964; Greene, 1966; Kissen, 1963; LeShan, 1966;

LeShan & Rezikoff, 1960; LeShan & Worthington, 1956).

Although the tone of discussion in many of these

reports suggests that the findings support such a

relationship, there is no direct evidence of a relationship

between psychosocial variables and the development of

cancer. These reports are characterized by serious

methodological problems that call into question any other

conclusions. The primary methodological problems concern

the failure to control for important epidemiologic factors,

the failure to consider important differences between

patients with various cancer types, and the reliance on a

retrospective design (Wellisch & Yager, 1983).











Because of the inherent methodological problems,

investigation of the relationship between mental states and

the development of cancer is now rarely, if ever, pursued.

The focus of research in more recent years has been on the

relationship between psychosocial variables and the

progression of cancer. The outcome that has been evaluated

in these investigations is either the first recurrence of

cancer or the length of survival from the illness.

Unlike the earlier studies, the investigations

concerned with the relationship between psychosocial

variables and the progression of cancer have apparently

developed from a body of literature concerned with how these

variables may affect survival. Although this literature

suggests certain hypotheses, the ideas stand as untested

theory. That these hypotheses remain untested appears to be

the result of methodological obstacles.

It has been, for example, suggested that certain

psychosocial variables have either or both a direct effect

on disease or an indirect effect. On one hand, it has been

suggested that certain psychosocial characteristics result

in differing host resistance to the tumor (Pendergrass,

1965) through alteration of endocrine or automatic function

(Stavraky, Buck, Lott, & Wanklin, 1968), and in general,

through enhancing the susceptibility to disease (Cassel,












1976; Lindsey, Norbeck, Carrieri, & Perry, 1981; Wortman,

1984). It has been postulated that social support may have

a buffering function, that it might influence the occurrence

of a stressful event, that it may affect the initial

appraisal of the event, or that it may alter coping or

adaptation.

The methodology and findings of several studies

concerned with psychosocial variables and the progression of

disease are particularly relevant to this study. These

include studies of attitudes and emotional expression

assessed at or around the time of the cancer diagnosis and

investigations that made similar assessments of patients

with terminal cancer.

The relationship between psychosocial variables and

survival from cancer was the focus of a report (Stavraky et

al., 1968). The survival of patients with various types of

cancer was studied by comparing subjects ( N = 204) in least

favorable and most favorable outcome groups to control

groups with the same stage of disease. An attempt was also

made to control for age, sex, and social class. These

authors reported that the group with the most favorable

outcome differed from all others in its high proportion of

individuals who had strong hostile drives without loss of

emotional control.











In the 1970s another investigation involving assessment

and five-year follow-up was carried out (Greer, Morris, &

Pettingale, 1979). The subjects included 69 breast cancer

patients who were assessed preoperatively, 3 and 12 months

postoperatively, and then annually for four years. The

authors reported a significant association ( p (.05) be-

tween the initial response and the disease outcome.

Patients whose initial responses were denial or fighting

spirit more frequently had a favorable outcome than those

initially showing a sense of helplessness and hopelessness.

In addition to these findings are those reported by

Rogentine et al. (1979) who measured psychological factors

against the first recurrence of cancer following curative

treatment. The control of disease variables was achieved by

limiting the sample ( N = 67) to patients with a single type

of cancer and with a similar stage of disease. These

authors report that patients who did not have a recurrence

expected more life adjustment in order to cope with their

disease than those who did have a recurrence.

The designs of these three investigations illustrate

two of the primary ways in which the variability in survival

due to disease and medical effects can be controlled. This

is an issue of central importance in this type of research.

Variability in the progression of disease and the survival

of cancer patients is known to be affected by disease and











medical variables including the site of the cancer, the

stage of the disease, and the treatment given for the

cancer.

The investigation by Stavraky et al. (1968) illustrates

the use of a comparison group as well as the use of the

delineation of the patient population as a means of

limiting variability due to disease effects such as cancer

site and stage. The second and third investigations (Greer,

Morris, & Pettingale, 1979; Rogentine et al.,1979) relied on

the delineation of the population as the measure of control

of this important part of the variability in survival.

A third approach to the control of variability is

illustrated by the work of Weisman and Worden (1975). This

research used a statistical procedure to address the control

of variability in survival due to disease and medical

variables. This methodology was the model for the present

study.

In this investigation, the relationship between psycho-

social variables and survival was studied through analysis

of information on preterminal and terminal cancer patients

representing six primary cancer sites ( N = 35). The

determination of their survival as relatively long or short

was made by comparing observed survival to the survival that

was expected. The expected survival for the patients was











based on regression analyses of medical and biological

information on a large number of deceased cancer patients.

Longer survivals were associated ( p (.05) with main-

taining good relationships with others and being receptive

to support. Shorter survival was associated ( p .05) with

depression and pessimism.


Statement of the Problem

There is a prevalent belief in our culture that mental

states affect the development and course of illness. This

belief is particularly evident in many of the explanations

suggested for the progression of cancer and for survival

from cancer that is longer or shorter than expected. These

beliefs frequently develop in an atmosphere of ignorance

concerning the medical and disease variables that are known

to affect survival and to contribute to what is expected for

patients with certain types of cancer.

Unfortunately, these beliefs have been encouraged by

reports of studies that fail to control for the effects of

these important variables. And, although the findings of

several carefully designed investigations suggest that

certain psychosocial variables are associated with longer or

shorter than expected survival from cancer, the findings

have been loosely interpreted by many in the public and

professional community as providing evidence of a causal

relationship.












The purpose of this study was to explore the relation-

ship between psychosocial variables and the survival of

elderly cancer patients when important biological, disease,

and medical variables are controlled. The focus was on the

relationship between psychosocial variables and survival and

on the extent to which the variability in survival could be

explained by a set of psychosocial variables. The contri-

bution of concurrent physical conditions other than cancer

to the patients' survival was also considered.

The significance of this study is related to the

methods that were used to identify and analyze the effects

of several kinds of variables on cancer patient survival.

Although research suggests that the survival of cancer

patients may be related to psychosocial variables, many

variables affect survival, including those related to the

disease and treatment. For this reason, careful

consideration must be given to the methods used to measure

the effects of complicated psychosocial variables. The

problems inherent in studying the effects of variables like

the will to live and the willingness to fight the disease

must be acknowledged and addressed.

The appropriate interpretation of findings concerning

the relationship between psychosocial variables and survival

depends on how and to what extent these issues are addressed.

This study was designed to clarify the relationship between











psychosocial variables and the progression of cancer by

identifying and controlling the variability in survival that

was due to biological, disease, and medical variables. The

focus was on the refinement of the procedure developed by

Weisman and Worden (1975) through improvements in the

measurement and evaluation of medical and disease variables.


Research Questions

The four research questions were stated as follows:

1. What psychosocial variables are positively

correlated with survival?

2. What psychosocial variables are negatively

correlated with survival?

3. What proportion of the variability in survival can

be explained by a set of psychosocial variables?

4. What proportion of the variability in survival can

be explained by a set of psychosocial variables and

co-morbidity?


Definition of Terms

The definitions given in this section are presented in

a sequence that reflects the relationships between the

concepts. The terms defined include those having to do with

cancer, cancer treatment, and with the variables studied in

this research.











1. The term cancer refers to a group of diseases of

unknown and probably multiple causes that occur in all human

and animal populations.

2. The term biopsy refers to a procedure in which

enough tissue is obtained to determine whether or not it is

cancerous.

3. The diagnosis of cancer refers to the date on which

the cancer diagnosis was proven by biopsy.

4. The site of the disease refers to the organ in the

body in which the cancer first developed.

5. The stage of disease refers to a standard measure

of the extent of the cancer at the time of diagnosis.

6. Histology refers to the microscopic characteristics

of the cancer cell that are described and classified at the

time of the biopsy.

7. Surgery refers to the treatment of cancer by manual

or operative means and includes excision of the tumor mass

and other methods of manual removal of the cancerous tissue.

8. Radiation therapy refers to the use of x-rays,

radioactive isotopes, and other similar forms of radiant

energy in the treatment of cancer.

9. Chemotherapy refers to the use of drugs in the

treatment of cancer.

10. The term hormonal therapy specifically refers to

the use of hormones for the treatment of cancer.











11. Curative treatment refers to treatments given for

cancer that are known to have the potential for bringing

about a cure for the disease.

12. Palliative treatment refers to treatments given for

cancer that are not known to affect a cure but which are

given in an attempt to control the development of the

disease.

13. The initial treatment is defined as medical

treatment for cancer that is delivered in the early phase of

the illness following the diagnosis. The initial treatment

includes treatments that are begun in the first four months

after diagnosis. More than one kind of cancer treatment may

be included in the initial treatment. These treatments may

be curative or pallative in intent.

14. Subsequent treatment refers to all medical

treatments for cancer initiated after the first four months

following the diagnosis. More than one kind of treatment

may be included in subsequent treatment. The purpose of

these treatments is generally palliative.

15. The term recurrence refers to the development of

cancer following curative treatment.

16. The term metastasis refers to the spreading of

cancer from the primary site.

17. Co-morbidity refers to concurrent disease or

physical conditions other than cancer that may contribute to

the patient's death.











18. The survival of the patients refers to the number

of months that the patient lived beyond the diagnosis of the

cancer.

19. Expected survival refers to the number of months

that the patient is expected to live after the diagnosis

when important biological, medical, and disease variables

are considered.

20. Relative survival refers to a comparison of the

patient's survival to their expected survival.

21. The term disease variable refers to a variable

aspect of the cancer process in an organ of the body. The

disease variables identified for study in this research

included histology, stage, and co-morbidity.

22. The term medical variable refers to variable

aspects of the medical treatment given for cancer, and in

the present study included the initial and subsequent

treatment.

23. The term biological variable is used to

differentiate between individual characteristics such as

age, race, and sex, and characteristics of the disease and

treatment.

24. Psychosocial variables refer to variable aspects

of mental states and human relationships including moods,

attitudes, perceptions, social support, and socioeconomic

status.











CHAPTER II
REVIEW OF THE LITERATURE

The relationship between psychosocial variables and

cancer has been studied through two distinct approaches. The

first consisted of investigation of the relationship between

psychosocial variables and the development of cancer. The

earliest studies approached the problem in this way. The

second approach consisted of investigation of the relation-

ship between psychosocial variables and the progression of

cancer.

The methodology and findings of both approaches to this

relationship are reviewed in this chapter. Studies of the

relationship between psychosocial variables and the develop-

ment of cancer are reviewed in order to develop a perspective

of the theoretical and methodological issues. Investigations

concerning psychosocial variables and the progression of

disease are discussed in greater depth insofar as the

findings of these studies are most relevant to the research

questions of this study.

The first section, Psychosocial Variables and the

Development of Cancer, includes theoretical concepts,

research findings, and an evaluation and summary of studies

that focus on psychosocial variables as possible causes of











cancer. Important biological concepts are summarized in the

first part of the section in order to clarify the bearing

that these variables have on the design of studies and the

interpretation of findings.

The second and third sections focus on studies of the

relationship between psychosocial variables and the progres-

sion of cancer. Because of the number of variables that have

been studied and the differences in the design of studies,

the review of this literature is divided into a discussion of

(a) investigations of variables that are largely psychologi-

cal in nature and (b) investigations of variables that are

primarily social. Findings related to socioeconomic status

are included in the latter section. Both the second and

third sections include theoretical concepts, research

findings, and an evaluation and summary of the studies. The

important medical and biological concepts related to the

progression of cancer are developed in the second section.


Psychosocial Variables and the Development of Cancer


Early reports of the relationship between psychosocial

variables and cancer focused on the possible role of these

factors in the development of disease. Following a discus-

sion of important concepts, the findings of studies are

reported as they relate to (a) intrapsychic conflicts, (b)

mental illness and stability, (c) life stress events, (d)

depression and hopelessness, and (e) emotional expression.











Theoretical Concepts

Biological and psychosocial concepts are central to

this literature. Although the majority of these studies gave

little consideration to biological variables, these variables

and the underlying concepts have been much more thoroughly

studied than psychosocial variables.

Biological concepts

The nature of cancer. The term cancer is generally

assumed to refer to a specific disease. However, as Haller

and Glick (1983) have pointed out, it encompasses over one

hundred distinct disease entities which are very different in

their characteristic signs and symptoms, impact on the

individual, and potential for cure or control. More than 270

types of human cancers have been recognized and defined by

their cellular characteristics (Terry, 1978). The destruc-

tive nature of cancer cells is most easily understood in

relation to normal cellular activity.

As the American Cancer Society (1981) has pointed out,

changes at a cellular level are constantly present in living

organisms. Millions of cells die each day and are replaced

in an orderly manner. Normal, healthy cells multiply, dif-

ferentiate into specialized types, and mature. As cells age

or are damaged, they are replaced by new, specialized cells

of the same type. Cells referred to as cancer cells are

those that have developed a permanent defect in their











metabolism causing them to multiply in an abnormal way

(Meissner, 1978). Cancer cells typically multiply without

organization and without the specialized differentiation that

characterizes the normal, healthy cell. If the growth of

cancer cells remains uncontrolled, normal tissues are

invaded, body functions are disrupted, and death will occur

(American Cancer Society, 1981).

Tumors, or neoplasms, represent masses of these cells

(Meissner, 1978). They are divided into two main groups,

benign and malignant (cancerous). A benign tumor does not

invade the normal tissues around it in a manner that typi-

cally disrupts body function or threatens life. As Goldfarb

(1983) has pointed out, a malignant tumor, on the other hand,

not only invades the tissues surrounding it but also gives

rise to secondary growths, called metastases, in other parts

of the body.

When it is recognized, cancer is not simply identified

in terms of the disorganization of the cells, but in terms of

the normal cells from which the cancer cells have developed.

As Meissner (1978) has pointed out, tumors arise from essen-

tially all tissues of the body. Four main types are identi-

fied: carcinomas, which arise from epithelial cells and tend

to be solid tumors; sarcomas, which develop from muscle,

bone, fat, and other connective tissues; lymphoid tumors; and

leukemias, which are cancers of the blood (American Cancer











Society, 1981). According to Bryan (1983), the vast majority

of human tumors, about 90%, are carcinomas. And, the

majority of research focusing on psychological and social

variables considers individuals with cancers of this type.

The amount of resemblance of a tumor to normal cells

and tissue and an estimate of its growth rate are considered

to be important biological factors in the course of the

disease and the potential for cure or control (Meissner,

1978). As Goldfarb (1983) has pointed out, the characteriza-

tion of cells in this way is referred to as grading.

This issue, that cancer is not one disease but many, is

an extremely important issue not only for biologic research

but for psychological and social study in this area as well.

The development of cancer. In a broad sense, advances

in the understanding of epidemiologic factors in cancers have

not resulted in a view of a simplified relationship but

rather in an appreciation of a remarkably complex, multi-

staged process.

According to Meissner (1978), the causes of the meta-

bolic defect in cancer cells are innumerable. Causative

factors may be intrinsic or extrinsic to the individual or

animal developing a cancer. Among the intrinsic factors that

may be casually related are heredity, age, race, sex, and

hormonal and immunological status. Among the extrinsic

agents implicated in the development of cancer are chemicals,











viruses, and such physical agents as solar and ionizing

radiation (Meissner, 1978). Bryan (1983) has suggested that

the review of data of various types and from many sources

indicates that environmental factors, especially chemicals,

are major etiologic determinants in as many as 60% to 90% of

the most frequent carcinomas in humans. However, as Meissner

(1978) has pointed out, current concepts also support a

theory that the metabolic change from a normal to an abnormal

cell often develops in a steplike manner, "as a result of the

interplay of multiple causative factors, some acting as the

initiating agent and then disappearing, others (or perhaps

the same agent) serve as the promoting factors at a later

date" (p. 31). And, furthermore, some tumors remain dormant

for long periods of time until some other factor, perhaps

originating in the host, stimulates them to further growth

(Meissner, 1978).

Psychological concepts

In the earliest studies concerning psychosocial

variables and the development of cancer, it was not unusual

for the disease to be taken as a focus for psychoanalytic

interpretation. Complicated speculation based on clinical

observation suggested the existence of a "precancerous per-

sonality." Other clinicians and researchers explored similar

lines of thought in studies relating particular psychological

traits, including patterns of emotional expression, to the











development of cancer. And, in recent years, considerable

attention has been given to the idea that loss may be ante-

cedent to the development of the disease.

Research Findings

LeShan (1959) noted the long history of consideration of

psychological factors and the development of cancer. He

pointed out that as early as the second century, Galen set

forth a belief that melancholic women were more likely to

develop cancer than those who were more confident and vital.

Eighteenth and nineteenth century physicians suggested a

relationship between emotional trauma and the development of

cancer.

Early twentieth century statements of these ideas took

the form of hypotheses tested through clinical observations

of small groups of cancer patients. In some cases, indi-

viduals with a particular site of cancer were the object of

study; in other cases, observations were made of individuals

with various types of cancer. These were uncontrolled and

largely speculative studies with a decidedly Freudian flavor.

Intrapsychic conflicts

For example, Reznikoff (1955) raised the question of

hormonal imbalance secondary to psychodynamic conflict in his

work which compared women with benign and malignant breast

lesions. In a 1952 report on the observations of 40 women,

Bacon, Renneker, and Cutler suggested that breast cancer











could be conceptualized as passive suicide precipitated by

guilt feelings and depression. And, along similar psycho-

analytic lines, an association was suggested (Renneker

et al., 1963) between breast cancer and a disturbance of

heterosexual impulses characterized by increased oral-

dependent needs following a disturbed object relationship.

Several writers (Bacon et al., 1952; Bahnson, 1969;

Reznikoff, 1955; Tarlau & Smalheiser, 1951) reported

observing inhibited sexuality in breast cancer patients.

A relationship between psychological variables and the

site of the cancer was also suggested. Booth (1969)

concluded that a cancer involved the organ most specifically

related to the frustrated psychophysiological object

relationship and suggested that cancer developed as an inter-

nalized substitute object. Tarlau and Smalheiser (1951) com-

pared women with breast cancer and cancer of the cervix and

concluded that oral conflicts were related to the development

of the former and genital conflicts to the latter. LeShan

and Worthington (1956) also suggested a possible relationship

between personality organization and the site of the neo-

plasm. And, in another investigation from the 1950s, Fisher

and Cleveland (1956) compared patients with interior and

exterior cancer and asserted that the exterior group had a

tendency to conceive of their bodies as surrounded by impene-

trable boundaries when compared to the interior group.












Mental illness and stability

The concepts of mental illness and mental stability

have also been suggested as variables in the incidence of

cancer. These concepts have been investigated both retro-

spectively and prospectively.

In two follow-up studies of patients with depressive

illness, Kerr, Shapira, and Roth (1969) and Whitlock and

Siskind (1979) found that cancer deaths were significantly

higher ( p <.05) than expected in males. However, these

findings were not confirmed by other researchers (Evans,

Baldwin, & Gath, 1974; Niem & Jaaskelainen, 1978) whose

results showed no increase in deaths from cancer among

patients with unipolar depressive illness. Other research

(Rassidakis, Kelepouris, Goulis, & Karraiossefidis, 1972)

reported a lower than expected incidence of deaths from

cancer among schizophrenic patients but, according to Fox

(1978), insufficient data were given to show that they

exercised proper controls.

In a prospective study by Hagnell (1966) a statisti-

cally significant association ( p <.05) was found between a

personality trait of "substability," said to be similar to

Eysenck's extraversion dimension, and cancer. However, both

the sample size (20 males and 22 females) and the statistical

analysis have been criticized (Fox, 1978).











Personal integration was the focus of study (Grissom,

Weiner, & Weiner, 1975) in a comparative investigation of

healthy subjects and patients with bronchial carcinoma or

emphysema. The authors reported that the cancer patients

achieved a lower personal integration score on the

Tennessee Self-Concept Scale. However, the prospective

investigation by Keehn, Goldberg, and Beebe (1974) supported

a view that emotional instability per se does not increase

the likelihood of cancer.

Life stress events

The findings of several studies suggested that life

stress events frequently preceded the appearance of several

forms of cancer (Bahnson & Bahnson, 1964; Greene, 1966; Horne

and Picard, 1979; Jacobs & Charles, 1980). In addition, a

number of other retrospective investigations reported a

particularly high incidence of cancer among individuals that

had lost an important emotional relationship, reported

marital problems, or separation of parents (Bahnson &

Bahnson, 1964; Fox, 1978; Greene, 1966; LeShan, 1966; Lombard

& Potter, 1950; Schmale & Iker, 1964, 1966). Cancer also was

reported to appear in higher than expected frequencies among

individuals that were widowed, divorced, or separated

(Greene, 1966; LeShan, 1966; Lombard & Potter, 1959).











Prospective studies have essentially supported the

contention that psychological factors associated with stress

are predictive of later cancer development (Greer & Morris,

1975; Hagnell, 1966; Harrower, Thomas & Altman, 1975; Thomas,

1976). Horne and Picard (1979) reported that individuals

that were subsequently diagnosed with malignant lung tumors

reported less job stability, lack of plans for the future,

and loss of a significant relationship in the preceding five

years relative to patients that developed benign lung tumors.

The notion of a role of traumatic separation in the

development of cancer has not, however, been supported by

other findings (Graham, Snell, Graham, & Ford, 1971; Greer &

Morris, 1975; Muslin, Gyarfas, & Pieper, 1966).

Depression and hopelessness

Depression and hopelessness are frequently asserted to

be characteristic of persons who develop cancer. Engel

(1967) noted the view of the giving up/given-up syndrome with

its attendant affects of hopelessness and helplessness as

being a frequent precipitant of disease in general. However,

most of the studies reporting in this area are based on

retrospective analysis of diagnosed patients; controls are

lacking.

According to one group of researchers (LeShan, 1966;

LeShan & Reznikoff, 1960; LeShan & Worthington, 1956) deple-

tion and depression earmarked patients who were experiencing











a serious difficulty in their lives prior to the diagnosis of

cancer. Bahnson and Bahnson (1964) claimed that denial and

repression together with depression are a feature of patients

with cancer. Renneker et al. (1963) also reported depressive

reactions prior to the onset of cancer and speculated about

the possibility of decreased host resistance due to depres-

sion. Schmale and Iker (1971) reported that cancer seemed to

develop in patients who reported "giving up" and feelings of

severe hopelessness.

With a different perspective on the importance of these

emotional states, Greene (1966) reported that a majority of

mothers of children with leukemia and lymphoma had been

depressed and/or anxious for weeks or months prior to the

onset of the child's disease.

Attempts to approach this issue in prognostic studies

include the work by Schmale and Iker (1966, 1971), in which

the presence of cervical cancer was significantly predicted

( Ep<.05) by a predisposition for experiencing hopelessness,

as assessed at interviews conducted before biopsy. In 1979,

Spence reported a reproduction of Schmale's work with

patients who were to be screened for cervical cancer by cone

biopsy. He found that he could predict outcome associated

with depression and hopelessness.











Emotional expression

One group of researchers (Abse et al., 1974) pointed out

that among the personality characteristics often attributed

to cancer patients are repression and denial, poor outlet for

emotional discharge, inability to express hostile feelings,

rigidity, impairment of self-awareness and introspection, a

tendency to self-sacrifice and self-blame, a "reality

orientation," and a predisposition for experiencing

hopelessness and despair.

Among the researchers to first focus on the relation-

ships between the development of cancer and characteristic

patterns of emotional expression were LeShan and Worthington

(1956). They contended that cancer patients characteristi-

cally have an inability to express hostile feelings. Reduced

aggressive expression was identified as a factor by both

Bacon et al. (1952) and Stavraky et al. (1968).

In the 1960s, the work of David Kissen was well-

respected for its attempts to study this issue in a

systematic manner and with controls. In his study of male

lung cancer patients, Kissen (1963) found that men with lung

cancer differed significantly ( p <.05) from controls with

other pulmonary disease in having restricted outlets for

emotional discharge. He and his associates (Kissen, Brown, &

Kissen, 1969) claimed to confirm this in 1969.











Studies in the 1970's of women with breast cancer lend

support to this idea. In a controlled study carried out by

Greer and Morris (1975), suppression of anger was found to be

correlated with the diagnosis of breast cancer. However, the

correlation was reported to reach statistical significance

( p <.05) only in women under age 50. Supression of anger

was also reported to be associated with cancer in two

controlled studies of women prior to biopsy for breast lumps

(Margarey, Todd, & Blizzard, 1977; Morris, Greer, Pettingale,

& Watson, 1981).

A study (Dattore, Shontz, & Coyne, 1980) comparing

individuals who developed cancer with those who did not lends

support to the idea that suppression of feelings occurs more

frequently among persons who subsequently develop cancer than

among control subjects. And, the findings of a longitudinal

study (Grossarth-Maticek, Siegrist, & Vetter, 1982) of 1353

inhabitants of a Yugoslav town from 1965 to 1975 suggested

that being a "passive receiver of repression" was associated

with the subsequent incidence of cancer.

Evaluation and Summary

The evaluation and summary of the literature relating

psychological variables to the development of cancer are

considered in two areas of discussion: (a) hypotheses and

methodological issues, and (b) summary of findings.











Hypotheses and methodological issues

As Crisp (1970) pointed out, studies that investigated

premorbid, or precancerous, personality factors leaned

heavily upon theory and speculation which was far beyond what

was immediately suggested by the data. The early studies

tended to search for specific personality types associated

with specific cancer types. As one group of reviewers

(Surawicz, Brightwell, Weitzel, & Othmer, 1976) pointed out,

personality was frequently defined in terms of psychodynamic

variables. Despite the great variety of hypotheses advanced,

according to Wellisch and Yager (1983) "no good hypotheses

exist that specify which personality factors might lead to

cancer for what specific reasons" (p. 145). In their

thorough analysis of this literature, they asserted that "the

best that those dealing in psychodynamics have been able to

do thus far is to offer interpretations as to why people who

already developed cancer have done so, but not why they

rather than others have the disease" (p. 146). Early studies

in this area are also characterized by serious methodological

problems. As Surawicz et al. (1976) pointed out, the dif-

ficulties with the approaches taken resulted in part

from the lack of carefully designed longitudinal studies.

As recognized in this review (1976), most studies did not

have control groups but were based on clinical obser-

vation of small numbers of cancer patients; the











few investigations that did employ control groups used poorly

matched controls.

Failure to consider important differences between

patients with various cancer types also seriously compromised

many of the early investigations. As Wellisch and Yager

(1983) point out, "To lump all cancers together is equivalent

to lumping all heart diseases, lung diseases, or anemia

together" (p. 146). Also, as has been previously noted,

important epidemiologic factors were rarely controlled; yet

they may be directly related to the appearance of cancer,

more than the psychological or personality variables.

Perhaps the most common characteristic of the research

methodology employed by these early investigations is a

retrospective design. In spite of attempts by some re-

searchers to employ a systematic approach, in the retrospec-

tive studies "the possibility cannot be excluded that the

reported psychological variables follow rather than precede

the development of cancer" (Greer & Silberfarb, 1982, p.

568). Even those observations made early in the diagnostic

process cannot be said to reveal phenomena that existed with-

out question, prior to the development of cancer (Wellisch &

Yager, 1983). As Greer and Silberfarb (1982) pointed out,

"Only prospective studies can provide proof of an association

between cancer and antecedent psychological variables" (1982,

p. 568). That is, the impact that having cancer might have












on an individual's responses must be considered. It is

likely that overriding anxiety may make it impossible to

study the basic personality prior to the onset of the disease

(Finn, Mulcahy, & Hickey, 1974).

As regards the evaluation of life stress events and the

occurrence of cancer, Sklar and Anisman (1981) noted that it

is likely that the cancer was present prior to and during

reported stress events since the signs and symptoms of cancer

may occur several years following the neoplastic change. In

addition, these reviewers questioned the validity of the

patient's views of their past stress history, especially

considering the physiological consequences of cancer on

mental and behavioral functioning.

A final methodological issue raised by Wellisch and

Yager (1983) concerned the validity of psychological tests

used in these studies. They noted the need to distinguish

between trait and state features of personality and pointed

out that the majority of psychological tests used in these

studies have not been tested for the characteristics on can-

cer populations, so their significance in this area is not

known.

Summary of findings

Conclusions regarding the role of psychological

variables on life stress events in the development of cancer












must be drawn cautiously and must remain stated as suggestive

of a relationship. From the viewpoint of two major

reviewers (Fox, 1978; Surawicz et al., 1976), the concept of

a specific carcinogenic personality has not been clearly

supported. According to Levy (1982), there is no direct

evidence for the development of cancer in animal models or

man associated with natural life trauma. And, as Wellisch

and Yager (1983) pointed out, "In patients who evidence

emotional or psychological developmental conflicts, all that

can be said is that such findings are associative, but not

that the findings cause cancer" (p. 149).

From their thorough review of animal and human studies

relating stress and cancer, Sklar and Anisman (1981) con-

cluded that despite the problems, these studies provisionally

suggest that certain psychosocial variables are associated

with higher cancer incidence. Among the variables frequently

noted are loss of a significant relationship or major life

change, depression and hopelessness, and restricted hostile

or aggressive expression.


Psychological Variables and the Progression of Cancer


Efforts to establish a relationship between psycho-

social variables and the development of cancer provide a

historical reference to the direction taken by more recent,











and more carefully designed investigations. In these

studies, a variety of psychosocial characteristics are

related not to the development of cancer but to the pro-

gression of the disease. Most often, the survival of indi-

viduals from diagnosis until death is used as the outcome

variable.

These investigations are concerned with the general

issue of whether psychosocial variables have a bearing on how

long an individual lives beyond a cancer diagnosis. Studies

that consider variables that are primarily psychological in

nature are considered in this section. Following a discus-

sion of important concepts, the findings are reported as they

relate to (a) attitudes and emotional expression, (b) atti-

tudes of those with advanced disease, and (c) disease

variables and psychological status.

Theoretical Concepts

Several concepts are central to this part of the

literature. Among the biological concepts are those related

to the growth of cancer and to cancer treatment. In addition

are concepts regarding possible psychosomatic mechanisms.

Medical and biological concepts

The microscopic characteristics of cancer cells

referred to through histology and grade are known to be

important prognostic indicators. Several additional

biological concepts are important to the prediction of












survival. These include the manner in which cancer pro-

gresses or spreads, the extent of spread at the time of

diagnosis, and the means by which efforts are made to

eradicate the disease or control its progression through

treatment. These concepts will be discussed in order to

develop a perspective for the evaluation and summary of the

related literature.

Local growth and metastasis. According to the American

Cancer Society (1981), when a small group of proliferating

cancer cells begins to invade and destroy adjacent healthy

tissues, cancer becomes a destructive process. This invasive

group of cells, the tumor mass, has already undergone changes

in size, shape, and nuclear pattern. The transition from the

normal character of cells to the malignant character that

results in invasion is a progressive process that may occur

rapidly or over many years.

In addition to the growth of the tumor in the original,

or primary site, cancer that remains uncontrolled spreads to

other distant sites in the body. This spreading of the

disease to distant sites is referred to as metastasis. It

is, as Wolberg (1983) has pointed out, this process that

usually kills cancer patients.

The spreading of tumor, or metastasis, can occur in

several ways. According to Wolberg (1983), metastasis can











occur through direct invasion of contiguous organs, through

implantation, and by passage through the lymphatic system or

blood stream. That different histologic types tend to

metastasize at different rates (and to particular sites) is

an important consideration in the design of studies seeking

to identify psychosocial variables in the progression of

disease. That is, the site and histology of the cancer must

be limited or controlled for when comparisons of survival of

patients are made.

Staging of disease. It is not uncommon for individuals

to hope that one with cancer will be given attention before

it is "too late." The concepts of "early" and "late" in

cancer care are integrally related to the extent of spread of

the disease from the primary site of development. As Haller

and Glick (1983) have pointed out, smaller and more localized

cancer can be treated more successfully and less radically.

Because of this, at the time treatment is initiated, an

important feature of an individual tumor is the extent of

spread, or metastasis. The assessment of the metastasis of

cancer is made through a process called staging which takes

into account such characteristics as tumor size, invasion

into adjacent tissues, metastasis to lymph nodes in the

region of the tumor, and metastasis to distant sites

(Haller & Glick, 1983).











The therapeutic approach to the illness and the prog-

nosis are determined, according to the authors cited above,

to a great extent by the stage of the disease (Haller &

Glick, 1983). Certain curative treatment approaches are not

considered when the disease is in an advanced stage. And,

while individuals with a particular type of cancer may be

similar in many other respects, their survival from the time

of diagnosis will differ to a great extent according to the

stage of the disease when treatment of any kind is initiated.

Hence, this biologic variable and its characterization

through staging must be considered in both design and

interpretation of studies identifying other additional

variables related to survival.

Treatment for cancer. The survival of an individual

with cancer is also related to the success of efforts to

intervene in the natural course of the disease. According to

the American Cancer Society (1981), the treatment of cancer

and precancerous lesions has one of three aims: prevention,

cure, or palliation. The specific aim of the treatment

depends on the histologic nature of the tumor and the stage

of the disease.

Cancer is generally considered cured if the individual

survives for five years, without a recurrence, following

initial detection and treatment. However, even when a cure











cannot be achieved, therapy that slows the growth or spread

of the tumor may prolong life significantly. Therapy with

this aim is referred to as palliation (American Cancer

Society, 1981).

Three basic treatment approaches are used in both

curative and palliative cancer care: surgery, radiation

therapy, and chemotherapy.

According to Haller and Glick (1983), surgery is

historically the first form of treatment for cancer. It

seeks to eradicate the tumor by the complete removal of all

cancerous and pre-cancerous cells (American Cancer Society,

1981).

In addition, many cancers are now treated with

radiation delivered either through an external beam or

through an implant of radioactive material. Because cancer

cells are more sensitive to x-rays and radioactive substances

than are normal cells, radiation therapy is used in the

prevention, curative treatment, and palliation of many

cancers either alone or with another treatment modality

(American Cancer Society, 1981).

According to Haller and Glick (1983), the use of drugs

in the treatment of cancer is a relatively new event that has

had a great impact on cancer care. They have pointed out

that chemotherapy, unlike surgery or radiation therapy, is a

systemic treatment. That is, both surgery and radiation











therapy treat cancer at a specific site while chemotherapy,

through its action in the bloodstream, travels through the

system and is potentially effective against cancer cells at

great distances from the primary site. As the American

Cancer Society (1981) has pointed out, most chemotherapeutic

agents disrupt the development and reproduction of cells.

Malignant cells grow and reproduce more rapidly than normal

cells and, hence, are more susceptible to the effects of

these drugs.

In recent years, treatment approaches to cancers have

been effectively combined in what is referred to as combined

modality therapy. According to Haller and Glick (1983), the

overall attempt of this approach, combining surgery,

radiation, and chemotherapy, is to maximize the curative

potential of each modality while minimizing morbidity.

Psychological concepts

Even when medical and biological variables such as

site, histology, and treatment are held constant, some indi-

viduals with cancer survive appreciably longer than others.

One of the theories advanced in explanation of this concerns

differing host resistance to the tumor (Pendergrass, 1965).

As Stavraky et al. (1968) have pointed out, factors have been

studied and psychosomatic mechanisms considered as possibly

affecting the growth and dissemination of cancer by altering

endocrine or autonomic function. As they have pointed out,

the growth rates of certain types of cancer depend to some












extent on hormones; in these types endocrine mediation of the

effect is very conceivable. And, as recognized by these

researchers, the influence of psychological states on en-

docrine and autonomic function has been extensively studied.

Research Findings

Because of the complexity of the relationships postu-

lated and the methodologic problems that exist, most research

efforts in this area have not attempted to simultaneously

establish the relationships and explore the biologic pathways

responsible for them. Recent research efforts have largely

been concerned with the description of psychological

variables related to survival through investigations that

represent significant improvements in design over the early

studies of psychological variables and the development of

cancer. What follows is a discussion of the major studies

related to this issue.

Attitudes and emotional expression

One of the earliest studies relating psychological

factors to the outcome of human cancer was conducted during

the 1960's by Stavraky et al. (1968). At the time of the

first contact with the Ontario Cancer Clinic, personality and

intellectual assessment was carried out with 204 patients (83

breast, 36 cervix, 28 lung, 57 other sites). The testing

included the Minnesota Multiphasic Personality Inventory

(MMPI), a projective technique, and the verbal component of











the Wechsler Adult Intelligence Scale (WAIS). Follow-up

ranged from 40-66 months. The outcome was defined as the

duration of survival from the date of admission to the date

of death. The analysis of data was based on comparison of

subjects in least favorable and most favorable outcome groups

to stage-matched controls with average outcome. These groups

were developed from cases whose survival times were in the

shortest or longest quartile of site and stage-specific life

tables calculated for the patients in the sample. An attempt

was made to control for age, sex, social class, site, and

stage. The results of the study were based on a final com-

parison of 23 patients with a most favorable outcome with 46

stage-matched controls of average outcome and 30 patients in

the least favorable group compared with 90 stage-matched

controls.

Stavraky et al. (1968) reported that the group with the

most favorable outcome differed from all others in its high

proportion of individuals who had strong hostile drives

without loss of emotional control. The group with the least

favorable outcome differed little from its control.

A second investigation (Greer, Morris, & Pettingale,

1979) involving assessment and five-year follow-up of

patients was carried out with breast cancer patients in the

1970s. Clinical and psychological assessments were made

preoperatively, 3 and 12 months postoperatively, then

annually for four years with a consecutive series of 69











breast cancer patients. All were less than 70 years old with

Stage I and II disease and all received simple mastectomy.

Twenty-five randomly selected patients also received post-

operative radiation therapy. Rating scales used in the

psychological assessment included one developed by the

authors for social adjustment, the Hamilton Rating Scale, the

Caine and Foulds Hostility Questionnaire, the Eysenck

Personality Inventory, and the Mill Hill Vocabulary Scale.

Variables evaluated included initial reactions, delay,

characteristic response to stressful events, ability to

express feelings, and occurrence of depressive illness or

loss five years prior to the diagnosis. In follow-up visits,

social adjustments, depression, and psychologic responses to

the diagnosis were re-evaluated. Based on the findings of a

pilot survey the responses to the diagnosis were grouped into

four categories: denial, fighting spirit, stoic acceptance,

and feelings of helplessness/hopelessness.

At the end of the five year follow-up period, 33 women

were alive with no evidence of disease, 16 were alive with

metastatic disease, and 18 had died of the cancer. The

authors reported no significant associations ( p) .05)

between five-year outcome and the following variables: age,

social class, reaction on discovery of cancer, delay,

habitual reaction to stress, expression of anger, depression,

hostility scores, or previous loss. There was a tendency for

the unmarried or those with poor marital relationships to











have a less favorable outcome. A significant association

( p< .05) between the initial response and outcome was

reported. Patients whose initial responses were denial or

fighting spirit more frequently had a favorable outcome than

those initially showing stoic acceptance or a helpless/

hopeless response.

Additional analysis of data from this series

(Pettingale, Philalithis, Tee, & Greer, 1981) showed no

evidence that biological factors biased the composition of

the groups or accounted for the observed differences in

outcome. And, some support was given to the notion of a

neuroendocrine or immune pathway for the observed effect by

additional findings from the same analysis of different

levels of serum immunoglobulin levels among the women with

different initial responses to the diagnosis.

Unlike the previous studies, a prospective investiga-

tion by Rogentine et al. (1979) measured psychological

factors against the first recurrence of cancer following

curative treatment. Experimental control was enhanced by

limiting the sample to patients with a single cancer type,

cutaneous malignant melanoma, and to those in either

clinical Stage II or unfavorable prognostic subcategories of

clinical Stage I. Two consecutive groups of white patients,

67 altogether, were evaluated one week after surgery with the

Recent Life Changes Questionnaire, a symptoms check list,












and the Locus of Control. A "melanoma adjustment score" was

also recorded based on the patient's rating on a scale of 1

to 100 the amount of personal adjustment needed to handle or

cope with having melanoma and having surgery for it.

For the purpose of data analysis, the first series was

divided into halves. In the first group, psychological

variables were identified which significantly ( (<.05) dif-

ferentiated patients who had a recurrence from those who had

not. These variables were then applied as a predictor of

recurrence for the second group.

According to the authors, the melanoma adjustment score

discriminated those with and without recurrence of melanoma

by one year ( < 05). Patients who did not have a recurrence

as a group expected more life adjustment in order to cope

with their disease. The independence of this variable from

biological factors was suggested by the finding that the

adjustment score did not correlate significantly with the

number of malignant lymph nodes identified through surgery;

this an important prognostic indicator. The authors reported

that combining the information on malignant lymph nodes with

the melanoma adjustment score improved the accuracy of

prediction in the group with recurrence. Depression, on the

other hand, did not predict recurrence.

Rogentine et al. (1979) suggested that "subjects scoring

low on the scale are using denial or repression of











the impact of the disease (lack of concern), while those

reporting a need for more adjustment are realistic in their

appraisal of the illness" (p. 653-654), and that the former

could be regarded as having reduced emotional reactivity.

Attitudes of those with advanced disease

A 1975 report (Weisman & Worden, 1975) illustrates a

methodology controlling for medical and biological variables

without the use of control groups. In this study, psycho-

social information was collected on preterminal and terminal

patients representing six primary sites: breast, cervix,

colon, lung, lymphoma, and stomach. Patients included in the

sample were those who were thought to possibly die in the

foreseeable future; actual survival beyond the assessment

ranged from four weeks to one year. The determination of

each patient's survival as relatively long or short was made

by comparing observed survival to the survival expected based

on regression equations previously calculated from medical

and biological information on a large series of deceased

patients.

Longer survivals were associated ( <.05) with

patients who previously had and were able to maintain good

relationships with others, who were receptive to medical and

emotional support, and who accepted the reality of their

illness without a sense of hopelessness, despair, or deep

depression. Social position was also positively correlated

( p<.05) with survival. Shorter survivals occurred in












individuals who reported poor social relationships, deepening

depression and pessimism when treatment failed, and according

to the authors, a desire to die, "a finding that often

reflects more conflict than acceptance" (Weisman & Worden,

1975, p. 71).

Another study of the attitudes of patients with

advanced disease is reported by Achterberg and Lawlis (1977).

In this investigation, a group of 126 patients with a broad

range of diagnoses of different cancer types, 90% of which

were widely metastatic, were evaluated for both psychological

and blood chemistry variables. The psychological battery

included the MMPI, the Locus of Control, the Fundamental

Interpersonal Relations Orientation -- Behavior, the Bem Sex-

Role Inventory, the Profile of Mood States, and a projective

measure, Image-Ca. There was a limited follow-up period of

two months.

According to the authors, psychological factors did

predict follow-up disease status. Blood chemistries

indicated no such relationship. The writers asserted that

patients who used a great deal of denial, saw their bodies as

having little ability to fight the disease, and expressed

significant dependencies on others were more likely to

receive a poor disease prognosis at two-month follow-up.

This work is severely compromised by failure to control

for treatment and disease variables and by the inability to











separate the possible effects of the disease process itself

on psychological responses.

Disease variables and psychological status

Despite attempts in the studies reviewed to control for

important medical and disease variables in psychosocial

analysis, few attempts have been made to evaluate the effects

of other organic factors on the psychological status of

patients, and subsequently, on their survival. A 1973 report

(Davies, Quinlain, McKegney, & Kimbell, 1973), explored these

relationships. A total of 46 patients with metastatic or

widely invasive cancer or with hematologic disorders

considered to be incurable were studied. All were receiving

or preparing to receive chemotherapy treatment. On the

average, patients had been diagnosed 28 months prior to the

interview. The average period of survival from the date of

the initial interview was 205 days. The minimum follow-up

period was eight months. Through a semi-structured inter-

view, information was elicited regarding the patient's

feelings about his illness, knowledge of the disease,

concerns over death, and ways of adaptation to the illness.

Additional test data were subsequently obtained on 18

randomly selected patients using the WAIS, Draw-A-Person,

part of the Thematic Apperception Test, time estimation, and

time production. All patients completed the Cornell Medical

Index, the Laxare-Klerman Personality Inventory, the Locus of

Control, and the Multiple Affect Adjective Checklist.











According to the authors, of importance in the findings

was the correlation of organic factors with better adjustment

to cancer. They reported that high scores on the constella-

tion "apathetic-given-up" correlated strongly with a shorter

survival time but also with a greater degree of illness.

According to the authors, these findings suggested that

psychological adjustment may not be directly related to an

earlier death but rather that "the psychological state, along

with the earlier death, is a product of the disease process"

(Davies et al., 1973, p. 470).

The relationship between organic factors and depression

in cancer patients was also noted by Sherman (1983) who

pointed out that much that has been labeled depression in the

cancer patient population may really reflect somatic illness.

He noted that among those medical problems that mimic

clinical depression, metastatic disease, electrolyte

disturbance, nutritional status, and drug-induced mental

depression are probably most common in hospitalized cancer

patients.

The findings of Derogatis, Abeloff, and Melisaratos

(1979) also suggest the need for further evaluation of the

relationship between physical factors, adjustment, and

survival. In this study, long-term survivors showed more

emotional distress, poorer adjustment to their illness and

more negative attitudes toward their physicians than the












short-term survivors. However, the short-term survivors had

a longer duration of prior chemotherapy.

Evaluation and Summary

The evaluation and summary of these studies are given in

terms of the hypotheses and methodological issues as well as

in a summary of the findings.

Hypotheses and methodological issues

Many of the studies concerned with the relationship

between psychological variables and the progression of cancer

addressed important methodological issues through their

design. However, the hypotheses or research questions were

stated in a very general way without delineation of specific

variables or mechanisms for their effect on disease and on

survival. This appears to be a consequence of the present

state of understanding of these complicated relationships and

seems to reflect the limited understanding of psychosomatic

relationships.

The control of important variables related to the

disease or treatment for the disease was achieved to a

greater extent in these investigations through the use of

control groups, by the specifications for the sample, or

through statistical means. And, although there were clear

improvements in the measurement of psychological variables,

the findings do not differentiate between state and trait

features of the personality or between more transient or

abiding psychological states.











Summary of findings

The research findings are summarized in the order in

which they were presented in the preceding section, that is,

in terms of attitudes and emotional expression assessed at or

around the time of diagnosis, attitudes and emotional states

of those with advanced disease, and the role of disease

variables as mediating variables in adjustment or

psychological status.

Attitudes and emotional expression. Individuals with a

favorable outcome or longer survival included those with

strong hostile drives without loss of emotional control at

and around the time of diagnosis (Stavraky et al., 1968).

Their reaction to the diagnosis was described as one in-

volving denial or a fighting spirit in contrast to those with

shorter survival who responded with a sense of helplessness

and hopelessness (Greer & Morris, 1975) and reduced emotional

reactivity in general (Rogentine et al., 1979). In general

terms, these individuals were observed to have more emotional

distress, poorer adjustment, and to express more negative

attitudes towards physicians (Derogatis et al., 1979).

Although these results suggest the importance of these

variables, additional findings by Greer and Morris (1975)

include no statistically significant ( p) .05) difference

between longer and shorter survivors in terms of expression

of anger, depression, or hostility.











In addition, it was reported by Rogentine et al. (1979)

that individuals with a more favorable outcome as defined by

recurrence free survival one year after diagnosis and

treatment expected that a great deal of adjustment would be

required.

Attitudes of those with advanced disease. During the

pre-terminal and terminal phase of the illness, patients with

advanced disease who had shorter survival were reported

(Weisman & Worden, 1975) to have expressed a sense of

pessimism, conflict, depression, and a desire to die. The

same authors reported that those with longer survival had a

realistic attitude about their illness without a sense of

hopelessness or fatalism.

Disease variables and psychological status. An

additional dimension of these complex relationships was

suggested by the findings of both Davies et al. (1973) and

Derogatis et al. (1979). In the first case (Davies et al.,

1973) an attitude of "apathetic-given-up" was strongly

correlated with a shorter survival time but also with a

greater degree of illness. In the second case (Derogatis et

al., 1979) the attitudes of long and short-term survivors

differed, but so did their treatment history. The short-term

survivors had a longer duration of chemotherapy prior to the

evaluation. Both reports lend support to the idea that both

psychological status and shorter survival may be related to

disease variables.











Social Support, Socioeconomic Status,
and the Progression of Disease

Few studies have specifically focused on social support

and the progression of cancer. However, the findings of

several studies regarding social support and mortality from

various causes are applicable to this issue in many respects.

The report of these findings is preceded by a discussion of

the concept of social support. The section concludes with a

description of the findings from studies of socioeconomic

status and the progression of cancer.

Theoretical Concepts

Conceptualizations of social support include a variety

of dimensions of both psychological and material support.

Social support has been described (Weiss, 1974) in terms of

the provision of attachment, social integration, opportunity

for nurturance, reassurance of worth, a sense of reliable

alliance, and obtaining of guidance as well as by the

expression of positive affect, the giving of symbolic or

material aid, and the affirmation of another person's

behaviors, perceptions, and views (Kahn, 1979). According to

Caplan (1974), social support is embodied in enduring

relationships which provide help for the individual in

mobilizing psychological resources and mastering emotional

burdens, sharing tasks, and providing material supplies.

And, Cobb (1976) has asserted that support consists of











information leading the person to believe that he or she is

cared about, esteemed and valued, and a part of a network of

mutual communication and obligation.

According to Berkman and Syme (1979), the research has

suggested that individuals living in situations characterized

by poverty and social disorganization as well as those

undergoing rapid social and cultural change appear to be at

increased risk of acquiring many diseases, including coronary

heart disease, cerebrovascular disease, and cancer. Other

investigations have suggested that social support may not

contribute directly to physical disorder (Wortman, 1984) but

may have a protective function and serve as a stress-

buffering or moderating role in health outcomes (Cobb, 1976;

Lindsey et al., 1981). However, as has been pointed out

(Murawski, Penman, & Schmitt, 1978), serious measurement and

conceptual problems exist. Berkman (1983) has pointed out

that this problem in life events/social support research

arises because stress and support are not operationally or

conceptually independent variables. She has asserted that

"many life changes -- in fact, the ones most consistently

associated with poor health -- are actually losses or breaks

in social ties" (Berkman, 1983, p. 748). It has been

hypothesized (Mueller, 1980) that much of the impact of life

events may result from the disturbance they introduce into

the individual's social network.











It has also been suggested (Cassel, 1976) that stress

enhances susceptibility to disease. Although little study

has been made of how social support protects people from

distress, and hence, influences health outcomes, both Cobb

(1976) and Wortman (1984) have speculated that more than one

mechanism may be involved. As Cobb has pointed out, two

major classes of theoretical views have been considered. The

first suggests a direct effect through neuroendocrine

pathways; the second suggests an indirect effect. Among the

indirect effects that has been suggested by Wortman is that

social support might influence the occurrence of the stress-

ful event being studied. Wortman also noted that once a

stressful event such as the diagnosis of cancer has occurred,

social support may influence the way the event is initially

appraised, and hence, influence subsequent outcomes. Both

Wortman and Cobb have suggested that social support may alter

coping and adaptation or that it may facilitate effective

coping by enhancing motivation to engage in adaptive or com-

pliant behaviors. Wortman has noted that an indirect effect

on coping might result from the enhancement of self-esteem,

and she has suggested that social support may also protect

people from the deleterious effects of stress by altering

their mood. Finally, Wortman has recognized that the rela-

tionship between social support and health outcomes is fur-

ther complicated by the fact that prognosis, coping, or pre-

vious adjustment influences the amount of support available.











Research Findings

The findings reviewed below on the relationship between

social support and mortality are derived primarily from

prospective studies with varying sample sizes. Among the

findings are results from two large prospective investiga-

tions (Berkman & Syme, 1979; House, Robbins, & Metzner, 1982)

and an analysis (Blazer, 1982, 1983) of data collected during

the validation of the Older Americans Resources and Services

(OARS) at Duke University. Reports on the role of socio-

economic status and mortality of individuals with cancer are

also briefly considered in this section.

Social support

Social networks, host resistance, and mortality were

evaluated (Berkman & Syme, 1979) in a nine-year follow-up

survey of 3725 men and women ages 30-69 studied by the 1965

Human Population Laboratory, Alameda County, California.

Each of the four sources of social contact studied was found

to predict mortality independently of the other three. The

strongest predictors were the more intimate ties of marriage

and contact with friends and relatives.

Marriage, contacts with close friends and relatives,

church membership and informal and formal group associations

made up the four categories of social contact studied by

Berkman and Syme. According to the authors, with few

exceptions, respondents with each type of social tie had











lower mortality rates than respondents lacking such connec-

tions. Married individuals in each age and sex group had

lower mortality rates than the nonmarried. The finding was

significant ( p< .05) for men but failed to reach signifi-

cance for women. Both men and women who reported little

contact with friends had significantly higher mortality

rates. Similar findings were reported with respect to church

membership and group affiliations. Individuals who belonged

to a church or temple had lower mortality rates than others

as did those with other group affiliations.

Additional analysis of the data involved the considera-

tion of a social network index that considered not only the

number of social ties but also their relative importance.

The findings revealed a pattern of increased mortality rates

associated with each decrease in social connection that was

not accounted for by an association between social disconnec-

tion and physical illness. The analysis was controlled for a

variety of health practices, and with the exception of a

cumulative index of health practices, these did not exert an

independent effect. Although the findings of this report

indicated that people lacking many social and community ties

were 2.5 times as likely to die in the follow-up period, the

authors pointed out that it is not known whether the risk

factors influence disease incidence or survival time. It is

also relevant (Berkman, 1983), that social isolation did not











seem to predict mortality more strongly in the older age

groups than in the younger groups. In this more recent

report, Berkman suggested that "it appears that social

isolation does not particularly diminish in its potency as a

risk factor for mortality in higher age groups; nor does it

increase" (p. 744-745). She also notes that the data did not

suggest that living alone, being single, or not having family

were indicative of social isolation. In fact, she notes that

most people, even older people, were apparently flexible in

their ability to form new relationships and make suitable

trade offs and substitutions.

The Tecumseh Community Health Survey (House et al.,

1982) was reported as a partial replication of the work by

Berkman and Syme reviewed above. Based on a cohort of 1322

men and 1432 women ages 35-69, this nine-year follow up

survey included structured personal interviews and medical

examination. Four measures of social relationships and

activities were studied: intimate social relationships;

formal organizational involvements outside of work; active

and relatively solitary leisure; and passive and relatively

solitary leisure.

Passive, solitary leisure activities were positively

associated with mortality among men. The more involved men

were in all of the other social relationships and activities,

the less likely they were to die. Results for women were less











strong and consistent. While passive leisure activities were

even more positively related to mortality among women, only

church attendance was significantly ( p <.05) and negatively

associated with mortality. The authors also noted that with

the exception of only one "anomalous result for women," there

was no evidence that satisfaction with relationships had any

significant association with mortality once the intensity or

frequency of an activity was controlled. Furthermore, in

concurrence with Berkman and Syme (1979), these writers

asserted that these data suggest that the relationship is not

a spurious product of preexisting illness.

An analysis of data (House et al., 1982), was also

carried out for deaths from cancer and ischemic heart

disease. Social relationships and activities generally were

negatively associated with mortality from both of these

causes for men and women. The finding was significant at the

.05 level even after controls for important risk factors were

included.

A 1982 report of findings by Blazer is based on a

secondary analysis of the community sample evaluated in the

fall of 1972 in Durham County, N.C., for the development of

the OARS Assessment Inventory. Three parameters of social

support shown to be independent were studied in this elderly

community population: roles and available attachments,

frequency of social interactions, and perceived social











support. The sample included 331 persons 65 and older,

selected randomly from the large group. Follow-up was made

30 months after the initial assessment. Among the variables

controlled for in a regression analysis were age, sex, race,

economic status, physical health status, self-care capacity,

depressive symptoms, cognitive functioning, stressful life

events, and cigarette smoking.

According to Blazer(1982), the three separate para-

meters of social support were significant ( p <.05) risk

factors for 30-month mortality (the causes of mortality were

not given). In apparent contrast to the findings reported by

House et al. (1982), the parameter with the highest predic-

tive value was perceived social support, a subjective

appraisal of the network.

An additional aspect of the data analysis (Blazer,

1983) concerned the impact of depression on the social

networks. Blazer reported that the depressed individuals

"were more likely to be older and to have alcoholic problems,

an increase in economic impairment, physical health

impairment, and impairment of activities of daily living"

(Blazer, 1983, p. 163). Both at the initial analysis and at

the 30 month follow-up, impairment in social support was

significantly more frequent in the depressed ( p< .05) and

this impairment appeared to increase at a faster rate than in

the nondepressed. However, Blazer contended that the data











presented suggest that these depressed individuals did not

suffer a relative decrease in social support over time when

compared with the nondepressed.

The impact of social support on mortality from cancer

was reported among the findings of both Greer and Morris

(1975) and Weisman and Worden (1975). In their study of 69

breast cancer patients, Greer and Morris reported a tendency

for unmarried or those with poor marital relationships to

have a less favorable outcome. The findings were not

statistically significant at the .05 level. Similarily,

terminal cancer patients with longer survivals in Weisman and

Worden's (1975) investigation were those with good relation-

ships with others who were able to preserve "a reasonable

degree of intimacy with family and friends until the very

last" (p. 71). Shorter survivals occurred in patients who,

among other things, reported poor social relationships.

Both short-term recovery and survival from breast

cancer have also been studied relative to stress, social

support and age (Funch & Mettlin, 1982; Funch & Marshall,

1983). In the analysis focusing on short-term recovery

(Funch & Mettlin, 1982) the support available to 151 female

breast cancer patients who were 3 to 12 months postoperative

was studied retrospectively. Three forms of support were

considered: social, professional, and financial. According

to Funch and Mettlin, social, professional and financial











support were all highly intercorrelated. The only variable

significantly related to physical recovery was financial

support ( <(.05).

Objective and subjective stress was considered in the

analysis (Funch & Marshall, 1983) that focused on survival

from breast cancer. A total of 208 white female breast

cancer patients diagnosed between 1958 and 1960 were inter-

viewed at the time of diagnosis and asked to report objective

and subjective stress and social support in the five year

period preceding their diagnosis. Survival was calculated 20

years later. The authors did not report control of any

variable other than stage in this analysis or the one that

preceded it (Funch & Mettlin, 1982).

In the findings, reports of life stresses had the

strongest association with survival in the youngest age

group. No relationship between marital status and number of

friends and relatives and survival was found for any age

group. For younger and older women in particular, involve-

ment was related to increased survival. In addition, objec-

tive stress was related to survival for the oldest group

while the relationship in younger women was stronger for

subjective stress. For women aged 46-60, neither stress was

related to survival.











Socioeconomic status and prognosis

As Wortman (1984) has pointed out, social support and

positive outcomes may also be influenced by such factors as

social class. She cites the work of Liem and Liem (1978) on

the role of economic stress and social support.

Investigations relating cancer survival rates to the

economic status of the patient sometimes suggest that poor

patients do not do as well as more affluent "private"

patients (Berg, Ross, & Latourette, 1977; Cohart, 1954,

1955a, 1955b, 1955c; Liechty, Ziffren, Miller, Collidge, &

Den Besten, 1968). As Berg et al. (1977) have pointed out,

many important explanations may exist for this relationship.

Important variations in treatment may exist as well as

differences in when medical help is sought, differences in

the general health and life expectancy of the patients,

differences in the behaviors of the cancers, and all the

cancer host interactions. Clearly, it is likely that socio-

economic status is a complex variable representing many

interrelated factors.

A series of investigations conducted in the 1950s by

Cohart (1954, 1955a, 1955b, 1955c) showed that lower socio-

economic status was associated with poorer survival for

patients with breast cancer, but not for females with cancer

of other genital organs or males and females with cancer of

the gastrointestinal or lung. However, data taken from the











Tumor Registry of the University of Iowa Hospitals (Berg et

al., 1977) on patients receiving treatment from 1940-1969 was

used in an 1977 analysis of economic status and survival and

indicated that indigent patients had poorer survival than

private patients for every cancer type for which there was

data. In this analysis, economic status was measured by the

means of payment for care: private payment, clinic pay, and

indigent.

Both the race of patients and the stage of illness at

the time of diagnosis have been considered as factors in this

relationship. There is some indication that blacks and other

disadvantaged population subgroups tend to be diagnosed and

treated when the disease is already well established, there-

fore limiting the prognosis. In one report (Linden, 1969)

one out of every two cancer patients in private hospitals had

localized disease at the time of diagnosis compared with only

one in four among public hospital patients. This finding

occurred across sites of cancer, sex, and age groups. A

similar relationship is suggested by the work of Howard,

Lund, and Bell (1980) which revealed that the metastatic rate

for black patients with breast cancer was much higher than

the rate for white patients. The relationship is also

suggested by Huguly and Brown's finding (1981) of a strong

relationship between race and socioeconomic status and stage

of disease at diagnosis with black and low socioeconomic

status in the less favorable diagnostic group.











However, a relationship between socioeconomic status

and survival persists even when stage and age are accounted

for (Berg et al., 1977; California Tumor Registry, 1963;

Lipworth, Abelin, & Connelly, 1970). For example, although

indigent patients in one investigation (Berg et al., 1977 )

had greater delays in seeking medical attention at all ages,

survival differences remained even after correcting for

delay. Similarly, data from the California Tumor Registry

(1963) showed poorer survival among the county hospital

patients even when stage and age were taken into account.

Despite the apparent agreement of these findings,

contradictory results from reliable sources exist. Note-

worthy is a report (Haenszel & Chiazze, 1965) from the

National Cancer Institute on the survival rates of cancer

sufferers. In this investigation of cancer end-results in

several USA cities, no significant differences ( p ).05) were

found in the survival rates of two groups differing in socio-

economic status as determined by the census tracts in which

they were domiciled. The findings of Berkman and Syme

(1979), based on a nine year follow-up, also suggest that

socioeconomic status is not an independent predictor of

mortality.

Evaluation and Summary

As in the preceding sections, the evaluation and

summary of the findings include a discussion of hypotheses,

methodological issues, and a summary of the findings.











Hypotheses and methodological issues

The prospective investigations concerned with social

support and mortality reflect the complexity of the concept

of social support and the various indices used to represent

it. Among the dimensions of social support evaluated in

these studies were marriage, contacts with close friends and

relatives, church membership, informal and formal group asso-

ciations, active and passive solitary leisure, perceived

social support, professional support (from professional care-

givers), and financial support. It has been suggested that

social support may have a protective function (Cobb, 1976;

Lindsey et al., 1981) through a direct effect on neuroendo-

crine pathways and/or through indirect effects (Wortman, 1984).

Many of the methodological problems that characterize

studies described in the preceding sections were overcome in

the large prospective investigations. However, there appears

to have been a loss of equal importance in the lack of

control for many of the biological variables or physical

factors that are known to affect morbidity and mortality.

The investigations concerned with socioeconomic status

and mortality also reflect the complexity of this concept and

the variety of indices used in its evaluation. In the

studies reviewed, socioeconomic status was evaluated by

comparing private paying patients with indigent patients,

patients in private hospitals with those in public hospitals,












patients residing in various census tracts, and by

Hollingshead's (1957) two factor rating of social position.

Many explanations have been suggested for this relationship.

As previously noted, these include variations in when medical

help is sought, in what kind of treatment is given, and

differences in the general health and life expectancy of the

patients.

Summary of findings

Despite the obvious complexity of the concept and

measurement variation, these reports do suggest a relation-

ship between social support and mortality. The findings of

studies reviewed suggest an increased rate of mortality for

those with little contact with friends and few social

connections (Berkman & Syme, 1979), the unmarried (Greer &

Morris, 1975), and those reporting poor marital relation-

ships (Greer & Morris, 1975) or poor social relationships in

general (Weisman & Worden, 1975). Passive, solitary leisure

activities, as opposed to more active solitary leisure

activities, were also reported to be associated with higher

mortality rates for both men and women (House et al., 1982).

Although age has not been found to be a statistically

significant factor in patterns of social support (Berkman,

1983), the findings of one analysis of this issue among older

individuals (Blazer, 1983) suggest that social support in

general is impaired among depressed individuals.











Lower mortality rates were found for married indi-

viduals in one investigation (Berkman & Syme, 1979). How-

ever, this relationship was not supported by the findings of

Funch and Marshall (1983) which showed no significant

relationship between survival of breast cancer patients and

marital status or the number of friends and relatives

reported by patients.

On the other hand, a greater degree of social involve-

ment was associated with lower mortality rates (Berkman &

Syme, 1979; House et al., 1982) or longer survival from

cancer (Funch & Marshall, 1983; Weisman & Worden, 1975). In

the investigation carried out by House et al., intimate

social relationships, organizational involvement, and active

solitary leisure activities were associated with lower

mortality rates among men, while church attendance was

associated with lower mortality rates among women.

The studies reviewed concerning the relationship between

socioeconomic status and survival do not lend themselves to a

clear and simple statement of this relationship. Some inves-

tigations reported that low socioeconomic status is related

to higher mortality rates ( Berg et al., 1977; California

Tumor Registry, 1963; Cohart, 1955a; Lipworth et al., 1970)

or shorter survival (Berg et al., 1977; California Tumor

Registry, 1963; Lipworth et al., 1970). The relationship

remained even when the stage of the disease and age are

considered.












A slightly different aspect of this relationship was

addressed by the findings of Funch and Mettlin (1982)

regarding the recovery of women from surgery for breast

cancer. In this investigation, the only variable that was

significantly related ( p .05) to physical recovery was

financial support.

Berkman and Syme (1979), however, reported that socio-

economic status was not an independent predictor and other

investigations (Cohart, 1954, 1955b, 1955c; Haenszel &

Chiazze, 1965) reported no statistically significant

differences in mortality relative to socioeconomic status.


Concluding Remarks

The concluding comments to this review of the litera-

ture are intended to highlight the apparently essential

features of a varied collection of investigations. As such,

considerable liberty is taken in summarizing complicated

issues and ideas. For a detailed discussion the reader is

referred to the relevant sections of the chapter.

The majority of reports concerned relationships between

psychological variables and the development of cancer. These

early reports were highly speculative and descriptive in

nature and were completely without a unifying theory. As

Wellisch and Yager (1983) pointed out, no hypotheses were

advanced that specified which personality factors might lead

to cancer for what specific reasons.











The most striking features of these reports are the

serious methodological problems, the reliance on retrospec-

tive analysis and an absence of carefully designed longitu-

dinal studies. In addition, the majority of studies

consisted of clinical observations of a small number of

patients. Most either lacked a control group altogether or

used poorly matched controls. As a result of this very broad

and general approach, there was a characteristic failure to

control for important epidemiologic factors and a failure to

distinguish between patients with various types of cancer and

various stages of disease. As regards the information

collected on the personality of the patients under study, the

ability of the interviewer or the psychological tests to

distinguish between trait and state features of the

personality was questionable.

At best, the findings of these reports can be said to

be associative. There is clearly no direct evidence for a

causal relationship between psychological variables and the

development of cancer. Among the variables frequently noted

by those reporting findings on the characteristics of persons

that develop cancer were a loss of a significant relationship

or major life change, depression and hopelessness, and re-

stricted hostile or aggressive expression.

The relationship between psychological variables and

the progression of cancer has also been explored by a number











of investigations, some of which represent major improvements

in design and methodology over the earlier reports. The

design and findings of these investigations are of greater

importance to the present study. The majority of these were

limited to the investigation of certain types and stages of

cancer or control for these important prognostic variables by

some aspect of the design of the study. The general trend in

these investigations was to measure the progression of cancer

in terms of the individual's survival. Hence, the findings

were most often reported in terms of characteristics of those

with longer, or more favorable survival, as opposed to

shorter, or less favorable survival.

Investigations that assess emotional expression and

attitudes at or around the time of diagnosis reported more

favorable, or longer, survival among individuals whose

attitude involved a fighting spirit, denial, and/or strong

hostile drives without a loss of emotional control. The more

favorable outcome was also associated with individuals who

showed a recognition of the great demand made on them to

adjust to the illness and treatment. On the other hand,

individuals with a less favorable outcome were characterized

as showing a generally reduced emotional reactivity and a

sense of helplessness and hopelessness.

Studies that assessed the emotional states of those

with advanced disease reported longer survival for those who











showed a realistic attitude about their illness without a

sense of hopelessness or fatalism. Shorter survival, on the

other hand, was associated with individuals who expressed a

sense of pessimism, conflict, and depression.

In addition, longer survivals were associated with

individuals who reported good social relationships and an

ability to maintain a sense of intimacy with others even in

the terminal phase of the illness. Shorter survivals,

conversely, were associated with individuals who reported

poor social relationships.

There were a few studies that specifically investigated

the relationship between social variables, that is, those

related to social support, and the progression of cancer.

However, several large prospective investigations suggested a

relationship between social support and mortality from

various diseases including cancer.

In general, lower rates of mortality were associated

with a greater degree of social involvement as measured by

the presence of intimate social relationships, organizational

involvement, and church attendance. Some differences were

reported in the type of involvement associated with lower

mortality rates for males and females. Higher rates of

mortality were associated with little social involvement as

measured by indices including contact with friends, social

connections, and poor marital or other social relationships.











There is no clear consensus of findings on the relationship

between marital status and mortality rates.

In addition to the various indices of social support

that have been investigated, the relationship between socio-

economic status and mortality rates has been studied. A

greater number of investigations have been carried out

relating this variable specifically to the survival of cancer

patients. And, although several studies reported that low

socioeconomic status was related to increased mortality rates

from cancer, additional investigations using other indices of

socioeconomic status did not reach similar conclusions.

Finally, in addition to these findings there was some

indication that organic factors played an important role as

mediating variables in adjustment. That is, adjustment and

shorter survival may both be related to disease variables

including the duration of prior treatment.













CHAPTER III
METHODS

Introduction

Research concerned with the causes of cancer and the

reasons for the progression of the disease has identified

certain variables that are clearly related to the survival of

individuals with cancer. These include disease variables

such as the primary site of the cancer cell and the stage of

the disease at the time of diagnosis. Medical variables, such

as the treatment given soon after the diagnosis and treatment

given later in the illness, also affect survival. However,

considerable variability exists even among indivi- duals who

are similar in these respects.

It has been suggested that some portion of the remain-

ing variability in survival can be explained by psychosocial

variables. And, the findings of several carefully designed

investigations lend support to this idea. Certain psycho-

logical and social characteristics are associated with longer

survival than would be expected, and other characteristics

are associated with shorter survival. In addition, the

relationship between disease, medical, and psychological

variables is a complicated one. This is illustrated by

findings which suggest that the degree and extent of the











illness have a bearing on psychological adjustment and

observed psychological characteristics.

The purpose of this study was to explore the relation-

ship between psychosocial variables and the survival of

elderly cancer patients when important biological, disease,

and medical variables are controlled. This control was

achieved by the methods used to determine the survival ex-

pected for individuals when these variables are considered.

Four research questions were initially posed. They focused

on the relationship between psychosocial variables and sur-

vival and on the extent to which the variability in survival

could be explained by a set of psychosocial variables. In

the process of interviewing individuals the influence of two

aspects of the illness on the individuals' psychological

status was observed. Both the length of time since the

diagnosis and the closeness to death at the time of the

interview appeared to influence psychological status.

Because the research methodology had not adequately con-

trolled for these disease variables, three additional

questions were formulated to study the relationships.

The report of the methods of this study begins with the

statement of the research questions and hypotheses and a

description of the design of the study. These sections are

followed by information related to the subjects, instruments,

procedure, and data analysis. This information is given in











two parts. The first part pertains to the methods used to

determine the expected survival of individuals with cancer of

the lung, breast, and rectocolon. The second part pertains

to the psychosocial analysis of the patients interviewed.

This part includes the methods used to determine relative

survival from expected survival and the methods used to test

the six hypotheses.


Research Questions and Hypotheses

The relationship between psychosocial variables and

survival was considered in four initial research questions.

Two questions specifically dealt with the correlations

between psychosocial variables and survival. The third

concerned the proportion of variability in survival that

could be accounted for by a set of psychosocial variables.

The fourth question was intended to further clarify the

contribution of disease variables to differences in survival.

It had to do with the combined effects of a set of

psychosocial variables and concurrent physical conditions

other than the cancer. This disease variable was called

"co-morbidity."

The four research questions were stated as follows:

1. What psychosocial variables are positively

correlated with survival?

2. What psychosocial variables are negatively

correlated with survival?











3. What proportion of the variability in survival can be

explained by a set of psychosocial variables?

4. What proportion of the variability in survival can

be explained by a set of psychosocial variables and co-

morbidity?

Three additional research questions were formulated

during the course of the patient interviews. These dealt

with the relationship between three disease variables and

certain psychosocial variables being studied. In this

instance, the disease variables were treated as the

independent variables. Psychosocial variables, which had

been independent variables, were treated as the dependent

variables.

The first of these three questions dealt with the

correlation between co-morbidity and psychosocial variables.

The second and third questions focused on variables defined

as a result of the observations made during the interviews.

The questions were as follows:

5. How are psychosocial variables related to co-

morbidity?

6. How are psychosocial variables related to the

duration of illness from cancer?

7. How are psychosocial variables related to the

individual's closeness to death?

Six null hypotheses were tested in this investigation.

They were stated in the following manner:











Hypothesis one: There is no relationship between

psychosocial variables and survival.

Hypothesis two: There is no relationship between a set

of psychosocial variables and survival.

Hypothesis three: There is no relationship between a

set of psychosocial variables, co-morbidity, and

survival.

Hypothesis four: There is no relationship between co-

morbidity and psychosocial variables.

Hypothesis five: There is no relationship between the

duration of illness from cancer and psychosocial

variables.

Hypothesis six: There is no relationship between the

closeness to death and psychosocial variables.


Design of the Study

This was a prospective study of the psychosocial

characteristics of terminal cancer patients and the

progression of their disease. The relationship between

psychosocial variables and survival was investigated using a

correlational design. In addition, the correlations between

certain disease variables and psychosocial variables were

studied through questions formulated during the course of the

study.











The study was designed to clarify the relationship

between psychosocial variables and survival by controlling

for other variables known to affect survival. The control was

achieved by using a value for survival that was based on

predictions for each of the cancer sites studied. These

predictions were made through the regression of the survival

rates of cancer patients on biological, disease, and medical

variables.


Part I: Determining Survival Expectations

Subjects

Survival expectations were determined through analysis

of information on deceased cancer patients. Three cancer

sites were selected for study. They were lung, breast, and

rectocolon. These sites were selected on the basis of the

relative frequency of their incidence in the general popula-

tion and their incidence specifically in the elderly popula-

tion which was the group selected for analysis in this study.

The population

Cancer deaths in the general population are largely

from cancers of the lung, breast, or rectocolon. As a

result, subjects with cancer of one of these sites are more

readily available. Data on deaths in 1978 (National Center

for Health Statistics, 1982) revealed that lung cancer was

the leading cause of cancer deaths among men. It was the

third leading cause among women. Rectocolon cancers were the











second leading cause of mortality from cancer among men and

women and breast cancer was the leading cause among women.

Also, deaths from lung, breast, and rectocolon cancer

occur most often among older men and women. Table 1

illustrates the age distribution of mortality from these

cancer sites. Nearly three-fourths of the deaths from

rectocolon cancer occurred among individuals 65 or over.

One-half of breast cancer deaths were among those 65 and

over. For all three sites, more than 20% of the deaths were

among those 75 and older.



Table 1



Age Distribution of Lung, Breast, and Rectocolon Cancer
Deaths: U.S.A., 1978

Cancer Site


Age in years Lung %a Breast %b Rectocolon %

35 64 45.10 50.24 27.42

65 74 34.10 24.36 30.66

75 and over 20.47 23.68 41.21


Note: Percentages for lung and rectocolon cancer reflect
males and females combined; breast percentages reflect
females only.
Note: Adapted from Vital Statistics of the United States,
1982.
a b c
n = 95,086. n = 34,329. n = 53,269.











The sample

In this study survival expectations were determined

through an analysis of information on 533 deceased cancer

patients who had been diagnosed and/or treated at Halifax

Hospital Medical center (HHMC) in Daytona Beach, Florida.

The cases for analysis were identified through the hospital

Tumor Registry which conducts follow-up on all cancer

patients diagnosed and/or treated in the hospital. The

prediction for lung cancer was based on 266 cases of lung

cancer diagnosed in 1979 and 1980 and included information on

all individuals diagnosed in those years who were deceased at

the time of data collection. The prediction for breast

cancer was based on an analysis of 101 deceased female

patients diagnosed in 1976, 1977, or 1978. The group

included all patients diagnosed in 1976 and 1977 who were

deceased at the time of data collection as well as 20 cases

diagnosed in 1978 which were included to reach an adequate

sample size. The cases diagnosed in 1978 were randomly

selected by including all in a series of 20 from alphabetized

records. For cancer of the rectocolon, expected survival was

based on an analysis of 166 patients diagnosed in 1977, 1978,

or 1979. This group included all deceased patients diagnosed

in 1977 and 1978 and 35 cases diagnosed in 1979 which were











included to reach an adequate sample size. A similar

sampling approach for the cases diagnosed in 1979 was used

for the rectocolon cancers.

The characteristics of the lung, breast, and rectocolon

cases are given in Table 2.



Table 2

Summary of Characteristics of the Sample

Site


Characteristic Lunga Breastb Rectocolonc

Age

M 66.33 65.44 71.70
SD 10.01 14.37 10.80
Mdn 67 69 72
Survival

M 7.56 27.17 17.96
SD 8.11 18.93 17.89

Race
White 246 91 157
Black 20 10 9

Sex
Male 190 0 70
Female 76 101 96


a N = 266. b N = 101. cN = 166.
N 266. N =101. N = 166.











The information on the 266 lung cancer cases was from a

group of individuals who ranged in age from 41 to 90 years at

the time of diagnosis. One-half were 67 years or older at

the time of diagnosis. Their survival ranged from 0 to 43

months after the diagnosis. The distribution of survival

values was positively skewed (1.72). These deceased patients

represented 89.31% of the lung cancer patients diagnosed in

1979 and 94.30% of all those diagnosed in 1980.

The 101 cases of breast cancer included individuals who

ranged in age from 27 to 95 years at the time of diagnosis.

The survival of the women in this group ranged from 0 to 77

months. The distribution of breast cancer survival in this

group was skewed (0.65) but less so than the survival of

those with lung cancer. Of the breast cancer patients

diagnosed in 1967, 62.24% were deceased at the close of data

collection. Of those diagnosed in 1978, 59.60% were

deceased.

The retocolon cancer group included 166 cases of

individuals who ranged in age from 46 to 96 years. The

survival of these individuals ranged from 0 to 72 months.

The distribution of values was positively skewed (1.06). For

this site, the deceased cases diagnosed in 197 represented

70.93% of all those diagnosed in that year. Of those

diagnosed in 1978, 78.57% were deceased at the close of data

collection; 72.73% of those diagnosed in 1979 were deceased.











Instruments

The instrument used in the collection of information

for determining survival expectations was a medical abstract.

Medical abstracts are used by hospital tumor registries to

facilitate follow-up and study of cancer patients. These

abstracts are routinely completed by the Halifax Hospital

Medical Center (HHMC) Tumor Registry staff on patients

diagnosed and/or treated at that facility. Information is

drawn from the hospital medical records. The criteria for

abstracting information from the medical records are set

forth in standard texts and manuals used by tumor registries

(American Joint Committee on Cancer, 1983; World Health

Organization, 1976).

As a result, little subjective judgement is involved in

the process. Although the format of the medical abstract was

changed slightly during the period from which the sample was

selected, the type of information abstracted and the manner

in which it was recorded remained unchanged.

Procedure

Information on cases of lung, breast, and rectocolon

cancer from the selected years was coded directly from the

medical abstracts to a standard International Business

Machines (IBM) coding form. This procedure was carried out

in the Tumor Registry of HHMC over approximately 80 hours.

Information on the lung cases was coded during January,











February, and March of 1982. Information on the breast and

rectocolon cases was coded during April, May, and June of

1984.1 At this time the abstracts of the lung cases were

reviewed to permit addition of those patients who had died

since the first data collection period.

The following information was extracted from the

medical abstracts specifically for this study: age, sex,

race, primary site of cancer, stage of cancer at diagnosis,

histology of the cancer, initial treatment, subsequent

treatment, and the patient's survival. These data were coded

for computer analysis in the following manner:

The patient's age was recorded as the number of years

from the date of birth to the date of diagnosis of the

cancer. Sex and race were coded as categorical variables

with the customary categories for each; that is, male,

female; white, black, hispanic, other. The primary sites of

lung, breast, and rectocolon were coded numerically. The

stage of cancer, an indication of the degree of spread of the

disease at the time of diagnosis, was recorded directly from

the medical abstract. The staging procedure used for




1The completion of coding was delayed until this time by
the patient interviews and by other work-related commitments.











all cases called for the assignment of the values 0 through 9

for the following categories: in situ, local, regional with

direct extension, regional with nodal involvement, regional

with direct extension and nodal involvement, distant

metastasis, lymphoma, and unknown. The histology of the

cancer was also coded directly from the histology recorded on

the abstract. In order to account for histologies that are

found in the cancers of the lung, breast, and rectocolon, the

following categories were included: epidermoid, large cell,

adenocarcinoma, small cell, inflammatory, mesothelial, and

spindle cell. The coding for initial treatment and subse-

quent treatment was devised to reflect the combination and

sequence of treatments given. Treatments begun during the

first four months following the date of diagnosis were

classified as initial treatments. New treatments begun

subsequent to that period were classified as subsequent

treatments. Four types of cancer treatment, surgery,

radiation therapy, chemotherapy, hormonal therapy, and all

possibilities of these in combination and sequence as given

in medical practice were used as categories for initial or

subsequent treatment. Finally, the patient's survival was

measured from the date of diagnosis to the date of death and

the number of months was recorded.











Analysis

The determination of survival expectations involved the

development of three linear regression equations that were

used to predict the survival of individuals with cancer of

the lung, breast, or rectocolon.

The development of the equations included the analysis

of three separate sets of data, each of which consisted of

biological, medical, and disease information on one of the

three cancer sites being studied. As previously noted, these

analyses were based on 266 cases of lung cancer, 101 cases of

breast cancer, and 166 cases of rectocolon cancer. The data

were derived exclusively from the medical abstracts. Table 3

summarizes the variables identified for this analysis and

gives the scale of measurement of each.



Table 3

Predicting Survival: Independent and Dependent Variables


Variables Scale of Measurement

Independent
Age Continuous
Sex Categorical
Race Categorical
Stage Continuous
Histology Categorical
Initial treatment Categorical
Subsequent Treatment Categorical

Dependent
Survival Continuous











Descriptive study

Eight variables were treated as independent variables

in these analyses. For the purpose of this study, age, sex

and race were included as biological variables, stage and

histology were included as disease variables, and initial and

subsequent treatment were included as medical variables.

Descriptive information was obtained on the eight

variables for each cancer site in order to compare the

important characteristics in these groups with the character-

istics of individuals interviewed for the psychosocial

analysis. Measures of central tendency and dispersion were

obtained for continuous variables and the frequency distri-

bution of values on categorical variables was studied.

Special attention was paid to the distribution of values on

each of the variables intended for use as independent

variables in the regression analysis.

The analysis of the data for the three cancer sites

also permitted evaluation of the distribution of the variable

survival, this being the variable intended for use as the

dependent variable in the regression analysis. The survival

of individuals with cancer is known to be skewed, more so for

some sites than others. As previously noted, this was

reflected by the data for lung, breast, and recto-

colon cancer. In the final regression equations selected for

prediction, the natural logarithmic transformation of











survival was used as the dependent variable to normalize the

distribution of values on that variable.

Inferential study

The inferential study of these variables consisted of a

series of regression analyses. In the first series of

regression analyses two linear models were tested for each of

the three cancer sites. These analyses were exploratory in

nature. The levels of statistical significance of the

partial regression coefficients of the independent variables

in these analyses were used as a criteria for the development

of equations for prediction.

The first of these two linear models included only the

main effects of the independent variables. The second linear

model included main effects and selected interaction effects.

Table 4 summarizes the variables used in the regression

analysis using the main effects only and the analysis using

main and interaction effects.

The regression analyses using the variables listed in

the table were carried out in an identical manner for each of

the three cancer sites with one exception. Since all cases

in the breast cancer group were female, the variable sex was

dropped as an independent variable for that site.

The second series of regression analyses involved tests

of regression equations for each cancer site that included

combinations of the independent variables that appeared to be











Table 4

Variables Tested in Two-Series Regression Analysis: All
Sites

Series

Variables One Two


Independent
Age + +
Sex + +
Race + +
Stage + +
Histology + +
Initial treatment + +
Subsequent treatment + +
Age x Stage +
Age x Histology +
Age x Initial Treatment +
Age x Stage +
Race x Stage +
Stage x Initial Treatment +
Age x Stage x Initial Treatment +

Dependent
Survival + +



the best predictors of survival. In these analyses the

natural logarithmic transformation of survival was used as

the dependent variable. One equation was subsequently

selected for each site to predict survival.

Four regression equations were developed for the lung

cancer cases. Table 5 summarizes the variables that were

used in these equations.

Two of the equations these included main effects only

and two included main effects and one interaction effect. An











Table 5

Regression Equations for Lung Cancer: Independent and
Dependent Variables


Model


Variables 1 2 3 4


Independent
Age + + + +
Stage + + + +
Histology + +
Initial treatment + + + +
Subsequent treatment + + + +
Stage x Treatment + +

Dependent
Log survival + + +


evaluation of the overall significance of the prediction

equation, the value of R the values of 2 for the partial

regression coefficients, and the number of independent

variables in the regression coefficients, and the number of

independent variables in the equation were used to select one

equation for use in predicting the survival of the lung

cancer patients interviewed for the psychosocial analysis.

The regression equations were tested for the breast

cancer cases. The variables used in these equations are

summarized in Table 6.

The equations included only main effects of the

independent variables being tested. An evaluation of the

equations as reported for the lung cancer cases was used












to select one of the two models for use in predicting the

survival of breast cancer patients who were interviewed.


Table 6

Regression Equations for Breast Cancer:
Dependent Variables


Independent and


Model


Variables 1 2


Independent
Stage +
Subsequent treatment + +

Dependent
Log survival + +



Table 7 summarizes the variables tested in three

regression analyses of the rectocolon cancer cases.


Table 7

Regression Equations for Rectocolon Cancer: Independent and
Dependent Variables



Model

Variable 1 2

Independent
Sex +
Stage + +

Dependent
Log survival + +












Two of the equations included only main effects of the

independent variables; one included main effects and one

one-way interaction effect. These equations were evaluated

and one of the three was selected for prediction of the

survival of rectocolon cancer patients interviewed.


Part II. Psychosocial Analysis

This section of the chapter pertains to the psycho-

social analysis and includes a report of the methods used to

answer the seven research questions. The psychosocial

analysis was based on interviews with 30 elderly cancer

patients and involved study of the relationships between

psychosocial, medical, and disease variables. Information is

reported in four major sections under the headings of

subjects, instruments, procedure, and analysis.

Subjects

The subjects in the sample for psychosocial analysis

were drawn from all individuals who were receiving treatment

for cancer at HHMC over a one-year period. Several criteria

were used to select subjects for study. The first was that

the patient have cancer primary to the lung, breast, or

rectocolon. Second, the patient must have been sixty or

above above at the time of the data collection. The vast

majority of patients with cancer of the lung, breast, or

rectocolon who receive terminal care at HHMC are at least 60

years of age. This criterion was used to exclude the very few











individuals of a younger age who would have been in this

sense, exceptional in a way that could not be adequately

evaluated. Third, the patient must have had a prognosis of

six months or less as judged by his or her primary physician.

The patients who met these criteria were identified by

the HHMC Oncology Resources Coordinator who routinely screens

all cancer patients admitted to the inpatient unit and by the

registered nurses staffing the outpatient chemotherapy unit.

Information on the patients identified for study was obtained

from the third week in February, 1982, through February 1,

1983. With the exception of a week each in March, April,

October, November, and two weeks in August, this information

was obtained through weekly visits to HHMC through November

of 1982. The number of visits each week ranged from one to

three. The information was obtained by phone during December

1982 and January 1983. As information was obtained, initial

visits in the inpatient or outpatient unit were scheduled.

A total of 57 patients were referred for study. Of

these 2 were contacted but declined to participate, 6 were

contacted but judged to be too ill to complete the inter-

view, 2 were contacted but proved to have hearing impair-

ments that prevented clear communication, and 14 were

discharged from the facility before interviews could be

scheduled. The remaining 33 patients were interviewed for

the psychosocial analysis. Two of these were subsequently




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