<%BANNER%>

Anxiety and Auto-Antibody Production to Heat Shock Protein 70 in Patients Undergoing Surgery for Suspected Endometrial Cancer

Permanent Link: http://ufdc.ufl.edu/UFE0024548/00001

Material Information

Title: Anxiety and Auto-Antibody Production to Heat Shock Protein 70 in Patients Undergoing Surgery for Suspected Endometrial Cancer
Physical Description: 1 online resource (42 p.)
Language: english
Creator: Sannes, Timothy
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2009

Subjects

Subjects / Keywords: Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Heat shock proteins (HSPs) are a class of chaperone proteins that protect cells from various forms of stress. Prior work has linked increased psychological stress to increased expression of HSPs in animal models and, more recently, in humans. This study investigated whether greater stress, depression, and anxiety were associated with greater HSP70 among women undergoing surgery for endometrial cancer. In a secondary aim, hypothalamic-pituitary-adrenal (HPA) functioning (i.e., salivary cortisol, area under the curve AUCg) was explored as a mediator of the relationship between psychological variables and HSP70. Participants were 38 women attending a Gynecologic Oncology clinic for evaluation of endometrial cancer. Participants underwent pre-surgical psychological assessment with the Life Experiences Survey (LES) and the Structured Interview Guide for the Hamilton Anxiety and Depression Scales (SIGH-AD) and a peripheral venous blood draw. HSP70 antibody concentrations were assessed using enzyme linked immunosorbent assay (ELISA). Controlling for biobehavioral confounds (ie. age, body mass index), neither greater impact of negative life events nor depression was associated with HSP70 (?=.28, p=.099; beta = .23, p=.16; respectively). However, a marginally significant association emerged between greater anxiety and greater HSP70 (beta =.32, p=.055), which accounted for 9.1% of the variance in HSP70 above and beyond relevant biobehavioral control variables. Cortisol (AUCg) was then examined as a mediator of this relationship. Cortisol was related to pre-operative anxiety (beta =.31, p=.035). However, cortisol was not significantly related to HSP70 when controlling for pre-operative anxiety; thus, cortisol failed to emerge as a mediator. Although based on a small sample, these findings suggest a moderate to large effect size between anxiety and serum HSP70 antibody concentration and anxiety and pre-operative cortisol in women undergoing surgery for endometrial cancer. Future research should examine other measures of HPA activation act as mediators of this relationship in a larger sample, as well as examining additional mood states and HSP protein expression in women with gynecologic cancers.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Timothy Sannes.
Thesis: Thesis (M.S.)--University of Florida, 2009.
Local: Adviser: Pereira, Deidre B.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2009
System ID: UFE0024548:00001

Permanent Link: http://ufdc.ufl.edu/UFE0024548/00001

Material Information

Title: Anxiety and Auto-Antibody Production to Heat Shock Protein 70 in Patients Undergoing Surgery for Suspected Endometrial Cancer
Physical Description: 1 online resource (42 p.)
Language: english
Creator: Sannes, Timothy
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2009

Subjects

Subjects / Keywords: Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Heat shock proteins (HSPs) are a class of chaperone proteins that protect cells from various forms of stress. Prior work has linked increased psychological stress to increased expression of HSPs in animal models and, more recently, in humans. This study investigated whether greater stress, depression, and anxiety were associated with greater HSP70 among women undergoing surgery for endometrial cancer. In a secondary aim, hypothalamic-pituitary-adrenal (HPA) functioning (i.e., salivary cortisol, area under the curve AUCg) was explored as a mediator of the relationship between psychological variables and HSP70. Participants were 38 women attending a Gynecologic Oncology clinic for evaluation of endometrial cancer. Participants underwent pre-surgical psychological assessment with the Life Experiences Survey (LES) and the Structured Interview Guide for the Hamilton Anxiety and Depression Scales (SIGH-AD) and a peripheral venous blood draw. HSP70 antibody concentrations were assessed using enzyme linked immunosorbent assay (ELISA). Controlling for biobehavioral confounds (ie. age, body mass index), neither greater impact of negative life events nor depression was associated with HSP70 (?=.28, p=.099; beta = .23, p=.16; respectively). However, a marginally significant association emerged between greater anxiety and greater HSP70 (beta =.32, p=.055), which accounted for 9.1% of the variance in HSP70 above and beyond relevant biobehavioral control variables. Cortisol (AUCg) was then examined as a mediator of this relationship. Cortisol was related to pre-operative anxiety (beta =.31, p=.035). However, cortisol was not significantly related to HSP70 when controlling for pre-operative anxiety; thus, cortisol failed to emerge as a mediator. Although based on a small sample, these findings suggest a moderate to large effect size between anxiety and serum HSP70 antibody concentration and anxiety and pre-operative cortisol in women undergoing surgery for endometrial cancer. Future research should examine other measures of HPA activation act as mediators of this relationship in a larger sample, as well as examining additional mood states and HSP protein expression in women with gynecologic cancers.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Timothy Sannes.
Thesis: Thesis (M.S.)--University of Florida, 2009.
Local: Adviser: Pereira, Deidre B.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2009
System ID: UFE0024548:00001


This item has the following downloads:


Full Text

PAGE 1

1 ANXIETY AND AUTO ANT IBODY PRODUCTION TO HEAT SHOCK PROTEIN 7 0 IN PATIENTS UNDERGOING SURGERY FOR SUSPECTE D ENDOMETRIAL CANCER By TIMOTHY STEWART SANNES A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORID A IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR TH E DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2009

PAGE 2

2 2009 Timothy S. Sannes

PAGE 3

3 To my father

PAGE 4

4 ACKNOWLEDGMENTS First, I thank Dr. Deidre Pereira for her incredible mentorship, guidance and encouragement through each part of this project. Her continued support allowed each step of this research endeavor to come to fruition. I also thank Dr. Edward Chan for his enthusiasm and expertise on all the biolo gical assays described in this work. Furthermore, I extend my gratitude to Stacy Dodd, for her help with data collection, data management and manuscript preparation. Additionally, I thank Dr. Sally Jensen, Dr. Linda Morgan and Lindsey Boegehold for their contributions to this project. I also acknowledge the members of my committee, Dr. Michael Robinson, Dr. William Perlstein and Dr. Sheila Eyberg. I thank my parents and family for their continued support. Specifically my father, for without his continu ed guidance and passion for research, this project would not have been possible. Additionally, I thank Elizabeth Spehalski, who served as a critical mentor to the theoretical background of the biological assays described in this work. Finally, I extend m y heartfelt appreciation to the women who participated in this research; without them, this research would not have been possible.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................................... 4 LIST OF TABLES ................................................................................................................................ 7 LIST OF FIG URES .............................................................................................................................. 8 ABSTRACT .......................................................................................................................................... 9 CHAPTER 1 INTRODUCTION ....................................................................................................................... 11 Heat Shock Proteins .................................................................................................................... 11 HSPs and Cancer ......................................................................................................................... 11 HSP70 and Endometrial Cancer ................................................................................................. 12 Antibodies to HSP ....................................................................................................................... 13 HSPs and Psychological Stress .................................................................................................. 14 HPA Functioning and Cortisol Measurement ........................................................................... 14 Current Study ............................................................................................................................... 15 2 METHODS .................................................................................................................................. 17 Design .......................................................................................................................................... 17 Participants .................................................................................................................................. 17 Procedures .................................................................................................................................... 18 Psychosocial Assessment ............................................................................................................ 18 Pre -surgical Life Stress ....................................................................................................... 18 Depressive and Anxious Symptomatology ........................................................................ 19 Physiologic Assessment .............................................................................................................. 19 HSP70 Antibody Measurement .......................................................................................... 19 Salivary Cortisol .................................................................................................................. 20 Salivary Cortisol Area under the Curve Analyses ............................................................. 21 Statistical Procedures .................................................................................................................. 22 3 RESULTS .................................................................................................................................... 24 Demographics .............................................................................................................................. 24 Health Status ................................................................................................................................ 24 Antibodies to HSP70 ................................................................................................................... 25 Investigation of Biobehavioral Control Variables .................................................................... 25 Life Stress .................................................................................................................................... 26 Depressive and Anxious Symptoms .......................................................................................... 26 Relationships between Psychological Variables and HSP70 antibodies ................................. 26 Cortisol as a Mediator of Pre -operative Anxiety and HSP70................................................... 27

PAGE 6

6 4 DISCUSSION .............................................................................................................................. 32 Study Limitations ........................................................................................................................ 34 Future Directions ......................................................................................................................... 35 LIST OF REFERENCES ................................................................................................................... 37 BIOGRAPHICAL SKETCH ............................................................................................................. 42

PAGE 7

7 LIST OF TABLES Table page 3 1 Comparisons of selected group for HSP70 antibody assay and the rest of sample ........... 30 3 2 Comparisons of race for HSP70 antibody assay and the rest of sample ............................ 30 3 3 Relationships between HSP70 antibodies and Potential Biobehavioral Control Variables ................................................................................................................................. 30 3 4 Predicting HSP70 antibodies from pre -operative life stress ............................................... 30 3 5 Predicting HSP70 antibodies from symptoms of depression .............................................. 31 3 6 Predicting HSP70 antibodies from symptoms of anxiety ................................................... 31 3 7 Path a of mediation analyses: Predicting Cortisol AUGg from symptoms of anxiety ...... 31 3 8 Path b of mediation analyses: Predicting HSP70 from symptoms of anxiety and Cortisol AUCg ........................................................................................................................ 31

PAGE 8

8 LIST OF FIGURES Figure page 2 1 ELISA curve -fit estimation for HSP70 antibodies ............................................................... 20 2 2 Cortisol as a mediator between psychological factors and HSP70 antibodies .................. 23 3 1 Cortisol as a mediator between psychological factors and HSP70 antibodies ................. 28 3 2 Area under the curve with respect to ground (AUCg) analyse s for cortisol for three select participants. Area is calculated using the trapezoidal formula for each day and averaged across the three days of collection. ....................................................................... 29

PAGE 9

9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science ANXIETY AND AUTO ANT IBODY PRODUCTION TO HEAT SHOCK PROTEIN 7 0 IN PATIENTS UNDERGOING SURGERY FOR SUSPECTE D ENDOMETRIAL CANCER By Timothy S Sannes May 2009 Chair: Deidre Pereira Major: Psychology Heat shock proteins (HSP s) are a class of chaperone proteins that protect cell s from various forms of stress. Prior work has linked increased psychological stress to increased expression of HSPs in animal models and, more recently, in humans T his study investigated whether greater stre ss, depression, and anxiety were associated with greater HSP 70 among women undergoing surg ery for endometrial cancer In a secondary aim, hypothalamic -pituitary -adr enal (HPA) functioning (i.e. salivary cortisol, area unde r the curve [AUCg]) was explored as a mediator of the relationship between psychological variables and HSP70. Participants were 38 women attending a Gynecologic Oncol ogy clinic for evaluation of en dometrial cancer. Participants underwent pre -surgical psychological assessment with the Life Experiences Survey (LES) and the Structured Interview Guide for the Hamilton Anxiety and Depression Scales (SIGH -AD) and a peripheral venous blood draw HSP 70 anti body concentrations were assessed using enzyme linked immunosorbent assay ( ELISA ). Controlling for biobehavioral confounds ( ie. age, body mass index), neither greater impact of negative lif e events nor depression was associated with HSP70 ( =.28 p =.099; = .23 p =.16 ; respectively). However, a marginally significant association emerged between greater anxiety and greater HSP70 ( =.32 p =.055), which accounted for 9.1% of the variance in HSP70 above and beyond relevant biobehavioral control

PAGE 10

10 variables. Cortisol (AUCg) was then examined as a mediator of this relationship. Cortisol was related to pre -operative anxiety ( =.31 p =.035). However, cortisol was not significantly related to HSP70 when controlling for pre -operative anxiety; thus, cortisol failed to emerge as a mediator. Although based on a small sample, these findings suggest a modera te to large effect size between anxiety and serum HSP 70 antibody concentration and anxiety and pre -operative cortisol in women undergoing surgery for endometrial can cer. Future research sh ould examine other measures of HPA activation act as mediators of this relationship in a larger sample, as well as examining additional mood states and HSP protein expression in women with gynecologic cancers

PAGE 11

11 CHAPTER 1 INTRODUCTIO N Heat Shock Proteins Heat shock proteins (HSPs) are characterized as a class of ubiquitously expressed chaperone proteins, which assist in specific intracellular and extracellular processes such as protein -protein interactions. These proteins receive th eir name from their ability to protect the cell from extracellular stressors such as inflammation, infection or toxic exposures (Mosser, Caron, Bourget, Denis Larose, & Massie, 1997) and therefore have come to be referred to as stress proteins (Marber e t al., 1995; Mestril, Chi, Sayen, O'Reilly, & Dillmann, 1994). HSPs, labeled according to their molecular weight in kilodaltons such as HSP70 or HSP90, protect cells by protect cells by assisting misfolded proteins to fold correctly or by t argeting them f or removal. I n this way they play critical roles in the intracellular trafficking of protein expression (Asea, 2003). While the exact physiologic role of these highly conserved proteins may still not be fully appreciated, it is thought that they aid in maintaining cellular homeostasis. They have recently been shown to have immunomodulatory properties, acting as both cytokine and chaperone molecules (Asea, 2003; Asea et al., 2000). HSP s and Cancer Given the critical role of HSPs in cell protection and apoptosis, many studies have focused on the role of HSPs in carcinogenesis. HSP overexpression has been observed within a number of different cancer cell lines, and extracellular levels of HSP may also influence cancer progression (for review see (Ciocca & Calderwood, 2005)). HSPs role in adaptive immunity has been exploited for novel cancer immunotherapy treatments (Tamura, Peng, Liu, Daou, & Srivastava, 1997; X. Y. Wang, Kaneko, Repasky, & Subjeck, 2000). In these investigations, HSPs were engineered fro m patients cancer cells and injected back into the patient, taking

PAGE 12

12 advantage of HSPs unique roll in the bodys adaptive immune system by allowing the patients T cells to recognize the tumor cells within the body. One possible linkage between extracellula r HSPs and carcinogenesis is through HSPs involvement in the inflammatory process, which is known to influence cancer development and metastasis (Coussens & Werb, 2002; Pikarsky et al., 2004). Recent experimental evidence demonstrates that HSP bind to crit ical immune cells (monocytes), which in turn release potent inflammatory signaling molecules such as tumor necrosis factor (TNF) alpha, interleukin (IL) 1beta and IL 6 (Asea et al., 2000). These molecules are associated with chronic inflammation, which is linked with a host of disease states such as diabetes, hypertension, and carcinogenesis (Aggarwal, Shishodia, Sandur, Pandey, & Sethi, 2006). HSP70 and Endometrial Cancer In endometrial cancer, HSP70 has received increasing attention in the evaluation of pathological characteristics of tumors as well as the clinical presentation of patients diagnosed with the disease. In Ciocca and Calderwoods (2005) review of HSP and cancer, the authors highlight three promising areas for the role of HSPs in cancer pr ogression, all of which are specifically implicated in the progression of endometrial cancer: 1) diagnostic implications (endometrial cancer patients with HSP70-positive tumors have been shown to have poorer survival than those patients with HSP -negative tumors (Nanbu et al., 1998)), 2) carcinogenesis (in endometrial cancer overexpression of HSP70 has been associated with p53 protein expression (Nanbu et al., 1996)) a known oncogene product) and 3) tumor cell differentiation (overexpression of HSP70 has been associated with a poorly differentiated state in endometrial cancer (Piura, Rabinovich, Yavelsky, & Wolfson, 2002)). Collectively, these data suggest HSPs, particularly HSP70, play a role in the progression of endometrial cancer.

PAGE 13

13 Antibodies to HSP Similar to HSP expression in extracellular tissue fluids, antibodies to HSPs also fluctuate when the body is exposed to noxious environmental stimuli. Thus high levels of HSP antibodies may represent the aftermath of high levels of circulating HSPs. Eleva ted antibodies to HSPs (compared to controls) are observed in the peripheral blood of those undergoing noise induced hearing loss (Yang et al., 2004), children with idiopathic thrombocytopenic purpura (Yang et al., 2004), patients undergoing heatstroke (Z. Z. Wang et al., 2001), patients with angina chest pain (Herz, Rosso, Roth, Keren, & George, 2006) and mothers giving birth to babies with birth defects (Child et al., 2006). In particular, antibodies to HSP70 have been observed in the serum of normal ind ividuals (Pockley, Shepherd, & Corton, 1998) as well as in response to disease states and environmental stimuli (Wu & Tanguay, 2006). Antibodies to HSPs have been observed in cancer populations, and may offer some prognostic value. For example, HSP90 antibodies have been found to be significantly higher in late stage ovarian cancer (Luo, Herrera, Soosaipillai, & Diamandis, 2002). HSP70 antibodies were significantly higher in non -small cell lung cancer patients compared to controls, while HSP90 antibod y levels were not (Zhong et al., 2003). Interestingly, relevant antibody levels were not related to tumor stage or histological characteristics in this investigation. Contrary to the supposition that HSP antibodies are physiological harmful, HSP90 antibodi es significantly predicted responses to neoadjuvant chemotherapy, whereas their absence was associated with greater lung metastases (although limited by a small sample size, N=3; Trieb et al., 2000). These studies suggest that, while the exact physiologi c role of these antibodies is unclear, they are involved in the carcinogenic process.

PAGE 14

14 HSP s and Psychological Stress HSPs are involved in protecting cells from a number of physiologic processes that carry the potential to damage cellular makeup, one of wh ich is psychological stress. For example, restraint stress, which is known to activate the hypothalamic pituitary adrenal (HPA ) axis, induces the expression of HSP70 mRNA in rats (Blake, Udelsman, Feulner, Norton, & Holbrook, 1991) HSP e xpression is enhanced by HPA -induced glucocorticoid production and by sympathetic nervous system (SNS) induced production of catecholamines (Blake, Klevay, Halas, & Bode, 1995). Extracellular stress, with the addition of proinflammatory cytokines, is also capable of indu cing the release of HSP70 from tumor cells (Barreto, Gonzalez, Kabingu, Asea, & Fiorentino, 2003) These studies suggest a relationship between the stress response system, or HPA axis, and HSP production in humans. However, relatively few studies have ex amined the relationship between psychosocial factors that are known to impact HPA axis functioning and HSP expression and impact in humans. HPA Functioning and Cortisol Measurement Given the association between HPA functioning and HSP expression, it may be useful and instructive to examine established measures of HPA functioning when investigating psychological variables and HSPs. One common measure of HPA functioning is quantifying the glucocorticoid cortisol (Kirschbaum & Hellhammer, 1994). Cortisol is produced by the adrenal glands with excitation of the HPA axis, and its release can be measured in the peripheral circulation as well as in salivary excretions. In fact, salivary cortisol is considered an accurate reflection of free (i.e., unbound) cortisol levels in the blood (Kirschbaum & Hellhammer, 1994). Prior research has demonstrated consistent relationships between cortisol and a number of psychological states, including depression (Burke, Davis, Otte, & Mohr, 2005), post traumatic stress disorder (M eewisse, Reitsma, de Vries, Gersons, & Olff, 2007), panic disorder (Abelson,

PAGE 15

15 Khan, Liberzon, & Young, 2007) and anxiety (Graeff, 2007). To our knowledge, no research has examined relationships between cortisol and HSP expression in humans, despite the pre ponderance of evidence suggesting cortisol as a reliable biological marker of HPA functioning and the reported relationships between HPA axis activation and HSP expression (Blake, Buckley, & Buckley, 1993; Blake et al., 1991). One recent investigation has correlated HSP60 expression with psychological variables in a civil servant population (Lewthwaite, Owen, Coates, Henderson, & Steptoe, 2002). In this study blood samples were obtained from 229 British civil servants who were asked about their socioeconom ic status and social isolation. Psychological distress was measured using the 30 item short version of the General Health Questionnaire. In this sample, socioeconomic status was inversely related to plasma HSP60 and high social isolation corresponded to t he group with the highest levels of HSP60. Notably, women with the highest levels of stress also exhibited the highest levels of plasma HSP60. Taken together, this data suggest a link between psychological factors and HSP concentrations in peripheral bloo d in a human population. Current Study The current study aims to draw a link between previously established relationships between psychological variables, HPA axis dysregulation, and HSP expression in a group of women undergoing treatment for endometrial c ancer during the perioperative period. Psychological stress is predicted to be particularly elevated for this group of participants leading up to their surgery, and the biological correlates of this stress (HPA dysregulation, HSP70 expression) are likely t o have particular relevance given the link between HPA functioning and cancer (Sephton, Sapolsky, Kraemer, & Spiegel, 2000), as well as HSPs implication in endometrial cancer (Nanbu et al., 1996; Nanbu et al., 1998). In the current study it is hypothesize d that high levels of psychological distress around the pre -operative period (high life

PAGE 16

16 stress, depression and anxiety) will be associated with increased levels of circulating antibodies to HSP70, and that this relationship will be mediated by HPA dysregul ation (cortisol).

PAGE 17

17 CHAPTER 2 METHODS Design The design of the current study was cross sectional and nonexperimental. Participants were women undergoing surgery for suspected endometrial cancer. Participants underwent psychosocial interview and peripher al venous blood draw at their pre -operative clinic visit. The relationships between stressful life events, symptoms of depression, symptoms of anxiety, and auto antibody levels to HSP70 were then analyzed. Cortisol was examined as a mediator of any signi ficant psychosocial HSP70 relationships. All analyses controlled for biobehavioral variables which were found to be related to levels of HSP. This study was conducted in accordance with the rules and regulations of the Institutional Review Board at the U niversity of Florida and is IRB approved (project number 692004). Participants Participants in this study were recruited as part of an ongoing study funded by the Amercian Cancer Society (ACS) and the National Cancer Institute (NCI; R03CA11748001A1) inv estigating psychoneuroimmunologic relationships in women undergoing surgery for suspected endometrial cancer. Inclusion criteria included suspected endome trial adenocarcinoma, scheduled to undergo total abdominal hysterectomy and bilateral salpingo oopher ectomy (TAH BSO) with or without pelvic lymph node dissection, and fluency in spoken English. Exclusi on criteria included recurrent or stage IIIb, IIIc, or IV endome trial carcinoma; pre -surgical che mo therapy or radiation therapy, metastasis to the uterine corpus from another site, current psychotic disorder, or current suicidal intent/plan.

PAGE 18

18 Procedures Women were recruited prior to undergoing surgery for suspected endometrial cancer from the University of Florida Shands Hospital Gynecology Oncology clini c. Eligibility was determined by brief chart review and physician consultation. Once the patient was deemed eligible following initial screening and agreed to have the researcher speak with her, the patient was presented with relevant study details. If t he patient was interested in participating, informed consent was then obtained and a brief additional screening assessment was performed. If the results of this screening were unremarkable, a brief psychosocial interview was scheduled for the participant s pre -operative appointment at the Gynecology Oncology clinic. Participants were reimbursed $20 at the conclusion of the interview for their time and participation. Psychosocial Assessment Pre -surgical Life Stress Pre -surgical life stress was assessed usin g the modified and abbreviated Life Experiences Survey (LES; (Sarason, Johnson, & Siegel, 1978) in order to assess the number of events deemed stressful over the last six months. The LES is a 60 item measure that assesses the frequency of specific life ev ents over the past 6 months and past 12 months, as well as the perceived impact, chronicity, and controllability of any events that were experienced. The abbreviated version of the LES included in the present study was developed by Leserman and colleagues at the University of North Carolina for use with chronically ill populations. This version was then modified to anchor health related events to the experience of being evaluated for or having cancer. Participants were asked to indicate which events occu rred over the prior six months and to rate the degree to which these events were experienced as stressful on a 5 point scale (from not stressful to extremely stressful). These impact scores were then summed to provide a life stress score, the possible range of which was 0 to 170. Abbreviated versions of LES have

PAGE 19

19 been used in a number of recent studies examining the association between impact of life events, immunity, and disease outcomes among women with chronic and life limiting medical illnesses (e. g., Pereira et al., 2003). The full LES has shown good internal consistency (Cronbach's alp ha=0.840.91), and sufficient tes t -retest reliability ( r=0.80) in cancer patient populations (Thewes, Meiser, & Hickie, 2001). Depressive and Anxious Symptomatology Depressive and anxious symptomatology were assessed using an abbreviated version of the Structured Interview Guide for the Hamilton Anxiety and Depression scales (SIGH -AD; (Williams, 1988). The SIGH -AD assesses anxious and depressive symptomatology over the past week through a series of structured questions. It has been widely used in patient populations and has adequate reliability and validity in medical settings (Cruess et al., 2000). An abbreviated version of the SIGH -AD was used in order to reduce patient burden and to remove items that would be confounded with endometrial cancer symptomatology (ie. genitourinary symptoms, weight loss). A total of 15 depression items and 9 anxiety items were retained in the present study. Possible depression subsc ale scores ranged from 0 to 44, while possible anxiety subscale scores ranged from 0 to 29. Higher scores indicated greater symptomatology. Because the version in use in this study was an abbreviated form, depression and anxiety scores from the present s tudy could not be compared to those in other published studies. Physiologic Assessment HSP70 Antibody Measurement Antibodies to HSP70 were measured by an Enzyme Linked Immunosorbent Assay (ELISA) kit (StressGen, Assay Designs, Ann Arbor, MI). This kit utilized recombinant human HSP70 pre coated to the wells of the recombinant HSP70 immunoassay plate to capture anti -human HSP70 antibodies present in human serum. The captured anti -human HSP70 antibodies was then

PAGE 20

20 detected with a hydrogen peroxidase conjugate d goat polyclonal antibody specific for IgG/A/M antibody molecules. After the substrate produced a readable change in optical density, the colors intensity of the color is measured in a micropl ate reader at 450nm. This HSP70 antibody ELISA kit generates a standard curve using a calibrated standard of anti-human HSP70 (IgG/A/M) antibodies isolated from pooled human sera. The resulting predicted values of HSP70 are reported in ng/mL (Figure 1). Anti-HSP70 IgG/A/M Concentration in ng/mL1000.00 800.00 600.00 400.00 200.00 0.00 0.00029 x + -0.021 Measured Absorbance at 450nm0.30 0.20 0.10 0.00 -0.10 Linear Observed Figure 2-1. ELISA curve-fit es timation for HSP70 antibodies Salivary Cortisol Participants collected saliva collection at 8:00, 12:00, 17:00 and 21:00 hours during each of the three days leading up to their pr e-operative study visit. Participan ts were asked to collect saliva

PAGE 21

21 samples using a Salivette (Starste dt, Inc., Newton, N.C.), which is a commercially available conical tube containing a cotton swab. Participants were asked to place the Salivette in their mouth until it was saturated (usually for one or two minutes). Participants were asked to record the t ime of each saliva collection, to ensure the accuracy of the time points in which the samples were collected. In addition, participants were asked to refrigerate the saliva samples until they were able to bring them to their pre -operative study visit, and they were provided with a small insulated cooler to transport the samples back to the research team. Once received by study personnel, saliva samples were frozen at 70 degrees Celsius by study personnel until they were shipped to Salimetrics Inc. (State C ollege, PA) for assaying. Cortisol levels were assessed using a commercially available Enzyme -Linked Immunosorbent Assay (ELISA) kit (Salimetrics, Inc., State College, PA). This commonly used laboratory technique utilizes a purified version of a substanc e of interest which is mixed with a specific enzyme in addition to the test sample (containing an unknown amount of the substance of interest). The solution then changes color based on the amount of the substance of interest present. The standard (or known amount of cortisol) and unknown cortisol compete for binding sites on the assay plate. The unbound structures are removed after an incubation period and the bound cortisol produces a reaction with the substrate that can be read by a standard plate reade r. Thus, this assay technique assumes that the amount of cortisol is proportional to the intensity of color change read by the plate reader. Salivary Cortisol Area under the Curve Analyses Research continues to grow examining relationships between psychoso cial factors and cortisol. There are a number up different approaches to measuring cortisol, including early morning cortisol peak, diurnal slope, area under the curve with respect to increase (AUCi), and area under the curve with respect to ground (AUCg; Vedhara, Tuinstra, Miles, Sanderman, & Ranchor,

PAGE 22

22 2006). Based upon the Salivary Cortisol Measurement guidelines outlined by the John D. and Catherine T. MacArthur Research Network on Socioeconomic Status and Health (Stewart & Seeman, 2000), cortisol was o perationalized using AUCg in the present study. As outlined in this report, AUCg appears to provide the most accurate and least controversial assessment of basal HPA axis activity and is thought to correlate the most strongly with psychological functioning. Cortisol AUCg was calculated using a published trapezoidal formula (Pruessner, Kirschbaum, Meinlschmid, & Hellhammer, 2003). Statistical Procedures All variables were examined for normal distributions to confirm that parametric statistics were appropr iate and if they were found non -normal, the appropriate transformation was applied. Initially, the predicted values of HSP70 were calculated as described above. Next, four potential biobehavioral control variables were investigated for their relationship with HSP70 antibody levels that have been associated with HSP70 antibody levels in prior research (Lewthwaite et al., 2002; Nanbu et al., 1996; Rea, McNerlan, & Pockley, 2001). Biobehavioral variables that were significantly associated with HSP70 at p .10 were retained as control variables in subsequent regression analyses. Statistics presented here utilized the general linear model (a) to predict circulating HSP70 antibody levels from psychological variables (negative life stress and depressive/anxious symptoms), and (b) to examine cortisol (AUCg) as a mediator of any significant relationships between these psychological variables and HSP70antibody levels using the methods of Baron and Kenny (1986; Figure 22 ).

PAGE 23

23 CORTISOL AUCg HSP 70 ANTIBODIES HSP 70 ANTIBODIES c a b c LIFE STRESS, DEPRESSION and ANXIETY LIFE STRESS, DEPRESSION and ANXIETY Fi gure 2 2 Cortisol as a mediator between psychological factors and HSP70 antibodies

PAGE 24

24 CHAPTER 3 RESULTS Demographics 115 women met eligibility criteria and were enrolled in this study. From this group, full psychosocial and HSP antibody data was collec ted on 38 participants. T test and chi square analyses revealed that there were no statistically significant differences (p>.05) between those who provided full psychosocial and physiologic data and those who did not across age, ethnicity, race or yearly i ncome (Tables 3 1 and 3 2) However, years of education was significantl y lower (t [36]= 2.53; p < .05; Table 3 1 ) and total annual income was marginally lower ( t [36]= 1.83; p = .08; Table 3 1) in the sub sample suggesting that the findings of the prese nt study may not be generalizable to higher socioeconomic status women. The 38 participants who provided full data ranged in age from 3584 ( M =61.6, SD =10.9). The majority of women primarily identified themselves as Caucasian (92.1%) and non Hispanic (97 .4%). Health Status The body mass index (BMI) of this select group of women ranged from 20.6 to 55.1 (M =36.1, SD =10.7). Five women were overweight (13.2%), while the majority of participants were obese ( n = 23; 67.6%), defined by a BMI as > 30 (World Hea lth Organization, 2006, Table 1). Most participants had Sta ge I endometrial carcinoma (68.4%) although 13.2% had Stage II disease, and 10.5 % had Stage III disease Two women (5.3 %) were found to have benign disease after surgery, and surgical stage was unreported on two others (5.3 %). Tumor grade classifies the severity of the tumor and includes the categories of benign, well -differentiated, moderately differentiated and poorly differentiated. In this sample, roughly

PAGE 25

25 half were classified as wel l -differen tiated (47.4%), with most of the remainder classified as moderately differentiated (36.8 %) A small group of patients were classified as benign and poorly differentiated ( n =2; 5.3% in each group). Tumor grade was unreported on two participants (5.3%). An tibodies to HSP70 After conducting the curve fit analysis (described above), the resulting predicted values of HSP antibodies ( M = 241.2 g/mL, SD = 202.9 g/mL) were non-normally distributed, (Skewness = 1.105, SE = .388; Kurtosis = 1.199, SE = .759). Thus, a square root transformation was applied to appropriately reduce skewness and kurtosis (Skewness = .146, SE = .383; Kurtosis = -.574, SE = .750). The range of the square root transformation of antibodies to HSP70 in this sample was from 1.0 to 29.4 ( M =14.0, SD =6.75). Investigation of Biobehavioral Control Variables Next, the relationship between the four proposed biobehavioral control variables (age, BMI, cancer stage and tumor grade) and HSP antibodies was examined to select relevant sample -specific control variables. Pearsons correlations were used to examine the relationships between the continuous predictors (age and BMI) and HSP70. One -way ANOVAs were conducted to examine relationships between tumor grade, cancer stage and HSP70 (Table 3 3). A ge was significantly negatively correlated with HSP70 ( r = .32; p = .05). BMI was marginally associated with HSP70 ( r = -.31; p = .073). Neither cancer stage ( F (3,33)=2.92; p =.26) nor tumor grade ( F (3,32)=1.88; p =.15) was significantly related with HSP70 antibody levels. Using Pedhazurs (Pedhazur, 1997) liberal guidelines for at least 15 subjects per predictor in regression analysis, age and BMI were combined into a single predictor in order not to exceed the recommended number of predictors (i.e., 2) for a sample size of 38. As such, an interaction term

PAGE 26

26 was created between age and BMI. This interaction term was highly correlated with HSP70 antibodies ( r = .48; p = .005). Life Stress Life stress scores ranged from 1.0 to 29.0 ( M =8.0, SD =6.0). The most c ommon life events endorsed in the 6 months prior to surgery were: a major worsening of a financial status (15.8%), having a major illness not related to cancer (15.8%), death of a relative (10.5%), death of a very close friend (10.5%), and working long ho urs (10.5%). Depressive and Anxious Symptoms The mean depression subscale score was 5.6 ( SD =4.6). The mean anxiety subscale score was 4.7 ( SD =5.6). Relationships between Psychological Variables and HSP70 -antibodies Three hierarchical regression analyses were run to investigate relationships between psychological variables and HSP70antibodies, all of which included the age/BMI interaction term in the first block as a control variable. In the second block, the psychological variable of interest was entere d (i.e., negative life stress, depressive symptomatology, anxious symptomatology). In the first analysis, negative life stress was entered into the second block. Negative life stress was not a significant predictor of HSP70 antibodies, = .28, t (27) = 1. 71, p = .099. Furthermore, it explained a nonsignificant (7.9%) amount of variance in HSP70 above and beyond age/BMI (Table 3 4), In the second analysis, depressive symptomatology was entered into the second block. However, depressive symptoms over the p ast week also failed to predict HSP70 antibodies = .23, t (30) = 1.45, p = .16. Depressive symptoms explained a nonsignificant (5.1%) amount the variance in HSP70 above and beyond age/BMI (Table 3 5).

PAGE 27

27 In the third analysis, anxious symptomatology was entered into the second block. In this instance, gr eater anxious sympomatology was marginally associated with greater antibodies to HSP70 after controlling for age and BMI, = .32, t (30) = 2.00, p = .055 (Table 3 6). Furthermore, pre -operative anxiety explained an additional 9% of the variance above and beyond age/BMI (Total R2=.32, F (2,30) = 6.94, p =.003). Cortisol as a Mediator of Pre-operative Anxiety and HSP70 Given that anxious symptoms were marginally significantly associated with HSP70 antibodies (Table 3 6; Figure 3 1 Path c), exploratory analys es were conducted to examine whether cortisol AUCg mediated the relationship between anxious symptoms and HSP70antibodies. Raw cortisol AUCg values ranged from 0.46 to 4.96 nmol/l ( M =1.91 nmol/l, SD =1.09 nmol/l). ). For illustrative purposes, cortisol AU Cg for a randomly selected sample of 3 parti cipants is presented in Figure 3 2 Next, the average AUCg cortisol data were log transformed to reduce skewness and kurtosis (pre transformation: Skewness = 0.964, SE = 0.434; Kurtosis = 0.247, SE = 0.845; pos t transformation: Skewness = 0.401, SE = 0.434; Kurtosis = 0.123, SE = .845). The age/BMI interaction term was retained as a biobehavioral control variable in all equations. In order to test Path a, cortisol was regressed on age/BMI (block 1) and anxious symptomatology (block 2). Greater anxious symptomatology was associated with greater cortisol, = .31, t (44) = 2.18, p =.035 (Table 3 7; Figure 3 1 Path a) and explained 11% of the variance in HSP70 above and beyond age/BMI. To test Path b, HSP 70 ant ibodies were regressed on age/BMI, anxious symptomatology, and cortisol AUCg. However, cortisol AUCg was not a significant predictor of HSP70 antibodies when controlling for age/BMI and pre -operative anxiety, = .27, t (20) = 1.55, p = .14 (Table 3 8; Fig ure 3 1 path b). Thus, path c could not be tested.

PAGE 28

28 ANXIETY CORTISOL AUCg HSP 70 ANTIBODIES (not tested) = .31, t (44) = 2.18, p =.035 = .27, t (20) = 1.55, p = .14 ANXIETY HSP 70 ANTIBODIES = .32, t(30) = 2.00, p = .055c a b c Figure 3 1 Cortisol as a mediator between psychological factors and HSP70 antibodies

PAGE 29

29 Figure 3 2 Area under the curve with respect to ground (AUCg) analyses for cortisol for three select participants. Area is calculated using the trapezoidal formula for each day and averaged across the three days of collection.

PAGE 30

30 Table 3 1. Comparisons of selected group for HSP70antibody assay and the rest of sample Hsp70 Da ta No Hsp70 Data df t P Sample Size 38 77 Age (yrs) M ( SD ) 61.58 (10.89 ) 60.47 (8.4 4 ) 37 0.63 .53 Yearly Income ($) M (SD ) ~$20,500 ($13,000) ~$26,0 00 ($19,000) 36 1.83 .08 Education (yrs) M ( SD ) 12.75 (2.6 1 ) 13.54 (2.7) 36 2.53 .02 Table 3 2 Comparisons of race for HSP70 antibody assay and the rest of sample Race Hsp70 Data No Hsp70 Data 2 P White ( n ) 35 65 .020 .89 Non White (African American) ( n ) 3 5 Table 3 3 Relationships between HSP70antibodies and Potential Biobehavioral Control Variables Correlation with HSP70 antibodies One way ANOVA F test (dfs) Age .32** BMI .31* Cancer Stage 1.41 (3, 33) Tumor Grade 1.88 (3, 32) Age/BMI Interaction Term .48*** p < .10 ** p < .05 ***p < .001 Table 3 4. Predicting HSP70 antibodies from pre operative life stress Step Number Predictor Variable R 2 R 2 F of R 2 1 Age/BMI .20 .44** .20 6.77** 2 LES Sum Score .28 .28* .08 2.92* n =30. Significance of Model, F (2, 27)=5.08 p =.013 p < .10; ** p < .05

PAGE 31

31 Table 3 5 Predicting HSP70 antibodies from symptoms of depression Step Number Predictor Variable R 2 R 2 F of R 2 1 Age/BMI .23 .48** .23 9.03** 2 SIGH AD Depression Sum Score .28 .23 .05 2.11 n =33. Significance of Model, F (2,30)=5.73, p =.008 p < .10; ** p < .05 Table 3 6. Predicting HSP70 antibodies from symptoms of anxiety Step Number Predictor Var iable R 2 R 2 F of R 2 1 Age/BMI .23 .48** .23 9.03** 2 SIGH AD Anxiety Sum Score .32 .32^ .09 3.99^ n =33. Significance of Model, F (2,30)=6.94, p =.003 ^ p =.055, **p < .05 Table 3 7. Path a of mediation a nalyses: Predicting Cortisol AUGg from sy mptoms of anxiety Step Number Predictor Variable R 2 R 2 F of R 2 1 Age/BMI .01 .09 .01 0.36 2 SIGH AD Anxiety Sum Score .11 .31** .10 4.75** n =47, Significance of Model, F (2,43)=2.57, p = .09 p < .10; ** p < .05 Table 3 8. Path b of mediation a n alyses: Predicting HSP70 from symptoms of anxiety and Cortisol AUCg Step Number Predictor Variable R 2 R 2 F of R 2 1 Age/BMI .31 .55** .31 9.65** 2 Cortisol AUCg .49 .26 .18 3.57** SIGH AD Anxiety Sum Score .27 n =25, Significance of Model, F (2,23)=6.35, p =.003 p < .10; ** p < .05

PAGE 32

32 CHAPTER 4 DISCUSSION Previous investigators have examined HSP expression and induced psychological stress in laboratory animal models (Blake et al., 1995; Blake et al., 1991), and more recently have extended this r esearch to relationships between HSPs and psychosocial stress in humans (Lewthwaite et al., 2002). No research to our knowledge has examined relationships between psychological variables and antibody production to HSPs in humans. Furthermore, investigating HSP production in a cancer population may have particular significance given the implication of HSP antibody and HSP expression in carcinogenesis (Ciocca & Calderwood, 2005). While the exact clinical relevance of HSP70 in endometrial cancer has yet to be determined, reducing pre operative anxiety in women undergoing surgery for endometrial cancer may have beneficial effects on HPA functioning (cortisol) as well as reducing circulating antibodies to HSP. The present study is the first to establish specifi c relationships between HSPs and anxiety, and the first to examine whether HPA functioning, as measured by cortisol, may potentially mediate this relationship. Endometrial cancer is the most common cancer of the female reproductive system and it is estimat ed that in 2008, 40,100 women will have been diagnosed and 7,470 will have died from the disease (National Cancer Institute, 2009; Ries et al., 2003). Fortunately, TAH BSO eliminates the disease and risk of recurrence in the majority of patients. Howeve r, despite the high success of treatment, as seen in the aforementioned survival rates, the experience often can affect patients quality of life and psychological well being (Klee & Machin, 2001). The current results contribute to a growing body of litera ture suggesting that psychosocial factors contribute to biological processes known to influence cancer metastasis and progression (S. Lutgendorf, Anderson, Sorosky, Buller, & Lubaroff, 2000; S. K. Lutgendorf et al., 2005).

PAGE 33

33 This relationship may also exist among healthy individuals. Indeed, HSP70 antibodies have been found in the circulation of healthy groups of people (Pockley et al., 1998; Rea, McNerlan, & Pockley, 2001) and similar HSP/anxiety relationships may be uncovered if anxiety were measured in h ealthy populations. Elevated circulating HSP60 was found in individuals with low socioeconomic status and, in women, with elevated psychological distress in a sample of healthy British Civil servants (Lewthwaite et al., 2002). Although the biological rel evance of elevated HSP expression among healthy populations may not be well understood at this time, it may be an early indicator of systemic inflammation(Xu et al., 2000) and a marker of risk for a number of disease states (Ciocca & Calderwood, 2005; Herz et al., 2006; Pockley, Georgiades, Thulin, de Faire, & Frostegard, 2003). The sample of participants presented here were primarily older ( M = 61.6) and the majority were diagnosed with Stage 1 disease (47.4%). Moreover, this sample had elevated BMIs ( M = 36.2), with the majority of participants falling into the obese classification (67.6%), both of which are known risk factors for developing endometrial cancer (Trentham -Dietz, Nichols, Hampton, & Newcomb, 2006). Given that this sample was older in age, had less advanced stages of disease and presented with elevated BMI, the results can likely be generalized to other women with endometrial cancer. However, the subsample of participants who were analyzed here had significantly lower total years of educati on and total annual income compared to the larger sample from which they were selected. This suggests that the present findings may not be generalized to women of higher SES or education levels. Women in this study endorsed low levels of psychosocial lif e stress, depressive and anxious symptoms. While there are no clinical cutoffs for the measures employed in this study, the means presented here fall in the lower third of each respective range of responses. In light of

PAGE 34

34 these results, it is noteworthy th at pre -operative anxious symptoms yielded a marginally significant relationship with HSP antibodies. While the low levels of life stress may indicate that this sample of women were not experiencing high levels of distressing life experiences, it is noteworthy that many of the life experiences documented were from the death of other relative or death of a close friend. These life experiences may represent bereavement, which could potentially represent a unique life stressor and may impact clinical outc omes differently than other forms of life stress (Norris & Murrell, 1990). In addition, it is striking that these relationships were demonstrated between HSP antibodies, given that the only human study examining psychosocial factors and HSPs investigated c irculating levels of the protein (Lewthwaite et al., 2002) and not autoantibodies. Measuring antibodies may represent a unique approach to the human bodys production of HSPs. For example, in the clinical literature, antibodies to HSPs have been related to breast cancer (Conroy, Sasieni, Fentiman, & Latchman, 1998), non-small cell lung cancer (Zhong et al., 2003), late -stage ovarian cancer (Luo et al., 2002), and is also associated with response to chemotherapy treatment (Trieb et al., 2000). Overall, b oth HSPs and their corresponding antibodies are related to the carcinogenic process suggesting that the exact physiological role of this class of proteins and their corresponding antibodies warrants further investigations. Study Limitations There are a num ber of limitations to the current study, and thus, the results should be interpreted with caution. Foremost of these limitations is the modest sample size, which limited statistical power. For instance, cortisol may have in fact mediated the relationship between anxiety and HSP70; however, the ability to detect this significant relationship may have been hampered by low statistical power. Another limitation is the low levels of anxious symptomatology in our sample of women. Yet another limitation is the cross -sectional design,

PAGE 35

35 which precludes us from drawing any conclusions of cause and effect (that pre -operative anxiety causes elevated levels of HSP antibodies). In spite of these limits important information was gained which may help direct future work in this area Future Directions Future directions will include increasing the sample size of participants that collect full psychosocial and biological data as this will allow the mediational hypotheses presented here to be fully examined. Furthermore, exa mining relationships between HSP antibodies and additional mood states (e.g. clinical depression, other forms of life stress) may warrant further investigation in a larger sample not limited by statistical power. As previously mentioned, performing an EL ISA assay for HSP70 antigens (proteins) on blood samples from this same group of women will allow for a comparison between HSP70 antibody levels and circulating HSPs further elucidating the role of these protective chaperone proteins. This additional as say would also allow for a more accurate comparison between the current results and other investigations of psychosocial factors and HSPs in human populations (Lewthwaite et al., 2002). In addition, measuring HSP70 expression and anxiety within a group of female age matched controls would allow the comparison of anxiety levels and HSPs in a group of individuals not undergoing surgery for suspected endometrial cancer. This would allow the opportunity to see if similar HSP70/anxiety relationships exist in he althy individuals further clarifying if HSP70 expression is unique to endometrial cancer patients. Moreover, establishing a comparison for pre operative anxiety levels would help clarify the level or degree of stress or anxiety measurable in the period prior to surgery for endometrial cancer. Given the limitation of only evaluating a single time point, it may prove advantageous to measure HSP over the course of patients treatment for endometrial cancer and include changes in psychological functioning

PAGE 36

36 wi th these future approaches. For example, the psychological stress leading up to the surgery date may dissipate after patients have recovered, and this could, in turn lead to reduced inflammatory markers and reduced levels of HSP70 antibodies. Collective ly, the present findings suggest that HSP70, a unique biological marker that is relevant in endometrial cancer progression and metastasis, is related to pre -operative anxiety. A number of investigators have suggested that HSPs may offer prognostic signifi cance in endometrial cancer patients and are related to histological characteristics of tumors and disease course (Bai, Chen, Xin, & Wang, 2003; Li, Peng, & Yao, 1999; Nanbu et al., 1998). Drawing links between psychological factors and disease course may be premature at this point. However, it is interesting and potentially important that psychological factors such as stress and anxiety may indeed alter a circulating component such as HSP 70 which reflect specific responses to carcinogenesis.

PAGE 37

37 LIST OF RE FERENCES Abelson, J. L., Khan, S., Liberzon, I., & Young, E. A. (2007). HPA axis activity in patients with panic disorder: review and synthesis of four studies. Depression and Anxiety, 24(1), 66 76. Aggarwal, B., Shishodia, S., Sandur, S., Pandey, M., & Se thi, G. (2006). Inflammation and cancer: How hot is the link? Biochemical Pharmacology, 72(11), 16051621. Asea, A. (2003). Chaperokine induced signal transduction pathways. Exercise Immunology Review, 9 25 33. Asea, A., Kraeft, S. K., Kurt -Jones, E. A., Stevenson, M. A., Chen, L. B., Finberg, R. W., et al. (2000). HSP70 stimulates cytokine production through a CD14-dependant pathway, demonstrating its dual role as a chaperone and cytokine. Nature Medicine, 6 (4), 435442. Bai, X. X., Chen, Y. Q., Xin, X. Y ., & Wang, W. D. (2003). [Expression and significance of heat shock protein 70, 90 in endometrial carcinomas]. Xi Bao Yu Fen Zi Mian Yi Xue Za Zhi, 19(1), 38 40. Barreto, A., Gonzalez, J. M., Kabingu, E., Asea, A., & Fiorentino, S. (2003). Stress -induced release of HSC70 from human tumors. Cellular Immunology, 222(2), 97 104. Blake, M. J., Buckley, D. J., & Buckley, A. R. (1993). Dopaminergic regulation of heat shock protein 70 expression in adrenal gland and aorta. Endocrinology, 132(3), 10631070. Blake, M. J., Klevay, L. M., Halas, E. S., & Bode, A. M. (1995). Blood pressure and heat shock protein expression in response to acute and chronic stress. Hypertension, 25(4 Pt 1), 539544. Blake, M. J., Udelsman, R., Feulner, G. J., Norton, D. D., & Holbrook, N. J. (1991). Stress induced heat shock protein 70 expression in adrenal cortex: an adrenocorticotropic hormone -sensitive, age -dependent response. Proceedings of the National Acadamy of Sciences U S A, 88 (21), 98739877. Burke, H. M., Davis, M. C., Otte, C., & Mohr, D. C. (2005). Depression and cortisol responses to psychological stress: a meta analysis. Psychoneuroendocrinology, 30(9), 846856. Child, D., Hudson, P., Hunter -Lavin, C., Mukhergee, S., China, S., Williams, C., et al. (2006). Birth defects and a nti heat shock protein 70 antibodies in early pregnancy. Cell Stress & Chaperones, 11(1), 101105. Ciocca, D., & Calderwood, S. (2005). Heat shock proteins in cancer: diagnostic, prognostic, predictive, and treatment implications. Cell Stress & Chaperones, 10(2), 86 103.

PAGE 38

38 Conroy, S. E., Sasieni, P. D., Fentiman, I., & Latchman, D. S. (1998). Autoantibodies to the 90kDa heat shock protein and poor survival in breast cancer patients. European Journal of Cancer, 34(6), 942943. Coussens, L. M., & Werb, Z. (200 2). Inflammation and cancer. Nature, 420(6917), 860867. Cruess, S., Antoni, M., Cruess, D., Fletcher, M. A., Ironson, G., Kumar, M., et al. (2000). Reductions in herpes simplex virus type 2 antibody titers after cognitive behavioral stress management and relationships with neuroendocrine function, relaxation skills, and social support in HIV -positive men. Psychosomatic Medicine, 62(6), 828837. Graeff, F. G. (2007). [Anxiety, panic and the hypothalamic pituitary adrenal axis]. Rev Bras Psiquiatr, 29 Suppl 1 S3 6. Herz, I., Rosso, R., Roth, A., Keren, G., & George, J. (2006). Serum levels of anti heat shock protein 70 antibodies in patients with stable and unstable angina pectoris. Acute Cardiac Care, 8 (1), 46 50. Kirschbaum, C., & Hellhammer, D. H. (1994). Salivary cortisol in psychoneuroendocrine research: recent developments and applications. Psychoneuroendocrinology, 19(4), 313333. Lewthwaite, J., Owen, N., Coates, A., Henderson, B., & Steptoe, A. (2002). Circulating Human Heat Shock Protein 60 in the P lasma of British Civil Servants Relationship to Physiological and Psychosocial Stress, Circulation (Vol. 106, pp. 196201): American Heart Association. Li, C., Peng, Z., & Yao, X. (1999). [Expression of heat shock protein (HSP70) in normal endometrium and endometrial carcinomas]. Hua Xi Yi Ke Da Xue Xue Bao, 30(3), 268270. Luo, L. Y., Herrera, I., Soosaipillai, A., & Diamandis, E. P. (2002). Identification of heat shock protein 90 and other proteins as tumour antigens by serological screening of an ovarian carcinoma expression library. British Journal of Cancer, 87(3), 339 343. Lutgendorf, S., Anderson, B., Sorosky, J., Buller, R., & Lubaroff, D. (2000). Interleukin6 and Use of Social Support in Gynecologic Cancer Patients. International Journal of Behavioral Medicine, 7 (2), 127142. Lutgendorf, S. K., Sood, A. K., Anderson, B., McGinn, S., Maiseri, H., Dao, M., et al. (2005). Social support, psychological distress, and natural killer cell activity in ovarian cancer. Journal of Clinical Oncology, 23(2 8), 7105 7113. Marber, M., Mestril, R., Chi, S., Sayen, M., Yellon, D., & Dillmann, W. (1995). Overexpression of the rat inducible 70 kD heat stress protein in a transgenic mouse increases the resistance of the heart to ischemic injury. Journal of Clinical Inves tigation, 95(4), 14461456.

PAGE 39

39 Meewisse, M. L., Reitsma, J. B., de Vries, G. J., Gersons, B. P., & Olff, M. (2007). Cortisol and post traumatic stress disorder in adults: systematic review and meta analysis. British Journal of Psychiatry, 191, 387392. Mestr il, R., Chi, S., Sayen, M., O'Reilly, K., & Dillmann, W. (1994). Expression of inducible stress protein 70 in rat heart myogenic cells confers protection against simulated ischemia induced injury. Journal of Clinical Investigation, 93(2), 759767. Mosser, D., Caron, A., Bourget, L., Denis -Larose, C., & Massie, B. (1997). Role of the human heat shock protein hsp70 in protection against stress induced apoptosis. Molecular and Cellular Biology, 17 (9), 53175327. Nanbu, K., Konishi, I., Komatsu, T., Mandai, M., Yamamoto, S., Kuroda, H., et al. (1996). Expression of heat shock proteins HSP70 and HSP90 in endometrial carcinomas. Correlation with clinicopathology, sex steroid receptor status, and p53 protein expression. Cancer, 77(2), 330338. Nanbu, K., Konishi, I ., Mandai, M., Kuroda, H., Hamid, A. A., Komatsu, T., et al. (1998). Prognostic significance of heat shock proteins HSP70 and HSP90 in endometrial carcinomas. Cancer Detection and Prevention, 22(6), 549555. National Cancer Institute. Endometrial Cancer. A ccessed January 15th, 2009, from http://www.cancer.gov/cancertopics/types/endometrial Norris, F. H., & Murrell, S. A. (1990). Social support, life events, and stress as modifiers of adju stment to bereavement by older adults. Psycho logy and Aging, 5(3), 429 436. Pedhazur, E. (1997). Multiple Regression in Behavioral Research: Explanation and Prediction: Holt Rinehart and Winston. Pereira, D. B., Antoni, M. H., Danielson, A., Simon, T., Efa ntis -Potter, J., Carver, C. S., et al. (2003). Life stress and cervical squamous intraepithelial lesions in women with human papillomavirus and human immunodeficiency virus. Psychosomatic Medicine, 65(3), 427434. Pikarsky, E., Porat, R. M., Stein, I., Abr amovitch, R., Amit, S., Kasem, S., et al. (2004). NF kappaB functions as a tumour promoter in inflammation associated cancer. Nature, 431(7007), 461466. Piura, B., Rabinovich, A., Yavelsky, V., & Wolfson, M. (2002). [Heat shock proteins and malignancies o f the female genital tract]. Harefuah, 141(11), 969972, 1010, 1009. Pockley, A. G., Georgiades, A., Thulin, T., de Faire, U., & Frostegard, J. (2003). Serum heat shock protein 70 levels predict the development of atherosclerosis in subjects with establish ed hypertension. Hypertension, 42(3), 235238.

PAGE 40

40 Pockley, A. G., Shepherd, J., & Corton, J. M. (1998). Detection of heat shock protein 70 (Hsp70) and anti -Hsp70 antibodies in the serum of normal individuals. Immunological Investigations, 27(6), 367 377. Pru essner, J., Kirschbaum, C., Meinlschmid, G., & Hellhammer, D. (2003). Two formulas for computation of the area under the curve represent measures of total hormone concentration versus time dependent change. Psychoneuroendocrinology, 28(7 ), 916931. Ries, L ., Eisner, M., Kosary, C., Hankey, B., Miller, B., Clegg, L., et al. (2003). SEER Cancer Statistics Review, 1975 2000: Bethesda, MD: National Cancer Institute. http://seer cancer. gov/csr/1975_2000. Sarason, I. G., Johnson, J. H., & Siegel, J. M. (1978). Assessing the impact of life changes: development of the Life Experiences Survey. Journal of Consulting and Clinical Psychology, 46(5), 932946. Sephton, S. E., Sapolsky, R. M., Kraemer, H. C., & Spiegel, D. (2000). Diurnal cortisol rhythm as a predictor of breast cancer survival. Journal of the National Cancer Institute, 92(12), 9941000. Stewart J., & Seeman, T. (2000). John D. and Catherine T. MacArthur Research Network on Socioeconomic Status and Health: Salivary Cortisol Measurement Acc essed February 12th 2009, from http://www.macses.ucsf.edu/Research/Allostatic/notebook/salivarycort.html#Measures Tamura, Y., Peng, P., Liu, K., Daou, M., & Srivastava, P. K. (1997). Immunotherapy of tumors with autologous tumor -derived heat shock protein preparations. Science, 278 (5335), 117120. Thewes, B., Meiser, B., & Hickie, I. B. (2001). Psychometric properties of the Impact of Event Scale amongst wome n at increased risk for hereditary breast cancer. Psychooncology, 10(6), 459468. Trentham Dietz, A., Nichols, H. B., Hampton, J. M., & Newcomb, P. A. (2006). Weight change and risk of endometrial cancer. International Journal of Epidemiology, 35(1), 1511 58. Trieb, K., Gerth, R., Holzer, G., Grohs, J. G., Berger, P., & Kotz, R. (2000). Antibodies to heat shock protein 90 in osteosarcoma patients correlate with response to neoadjuvant chemotherapy. Br J Cancer, 82 (1), 85 87. Vedhara, K., Tuinstra, J., Miles J. N., Sanderman, R., & Ranchor, A. V. (2006). Psychosocial factors associated with indices of cortisol production in women with breast cancer and controls. Psychoneuroendocrinology, 31(3), 299311. Wang, X. Y., Kaneko, Y., Repasky, E., & Subjeck, J. R. (2000). Heat shock proteins and cancer immunotherapy. Immunological Investigations, 29(2), 131 137.

PAGE 41

41 Wang, Z. Z., Wang, C. L., Wu, T. C., Pan, H. N., Wang, S. K., & Jiang, J. D. (2001). Autoantibody response to heat shock protein 70 in patients with heatst roke. The American Journal of Medicine, 111(8), 654657. Williams, J. (1988). Structured Interview Guide for the Hamilton Depression and Anxiety Scales (SIGH -AD). New York State Psychiatric Institute, New York, NY World Health Organization, (2006). BMI C lassification. Accessed on February 6th, 2009. from http://www.who.int/bmi/index.jsp?introPage=intro_3.html Wu, T., & Tanguay, R. M. (2006). Antibodies against heat shock proteins in environmental stresses and diseases: friend or foe? Cell Stress Chaperones, 11(1), 1 12. Xu, Q., Schett, G., Perschinka, H., Mayr, M., Egger, G., Oberhollenzer, F., et al. (2000). Serum soluble heat shock protein 60 is elevated in subjects with atheroscler osis in a general population. Circulation, 102(1), 14 20. Yang, M., Zheng, J., Yang, Q., Yao, H., Chen, Y., Tan, H., et al. (2004). Frequency -specific association of antibodies against heat shock proteins 60 and 70 with noise induced hearing loss in Chines e workers. Cell Stress Chaperones, 9(2), 207213. Zhong, L., Peng, X., Hidalgo, G. E., Doherty, D. E., Stromberg, A. J., & Hirschowitz, E. A. (2003). Antibodies to HSP70 and HSP90 in serum in non-small cell lung cancer patients. Cancer Detection and Preven tion, 27(4), 285290.

PAGE 42

42 BIOGRAPHICAL SKETCH Timothy Sannes graduated with honors from the University of North Carolina at Chapel Hill in 2 004 with a Bachelor of Arts in psychology. Following graduation, Mr. Sannes worked as a Research Assistant at the Uni versity of North Carolinas School of Medicine in the Department of Psychiatry. He then completed a Fellowship at the National Institute of Health in Complementary and Alternative Medicine investigating novel approaches to cancer treatment and recovery. T i mothy is majoring in clinical p sychology at the University of Florida and received his M.S. in the spring of 2009. He is focusing his studies on psychoneuroimmunology and integrating his interest in alternative and mind body therapies into these studies. He is currently pursuing his doctorate in clinical p sychology.