Copyright © 1998 Elsevier Science Ltd. All rights reserved.
8.09
Cancer
BARBARA L. ANDERSEN and DEANNA M. GOLDEN-KREUTZ
Ohio State University, Columbus, OH, USA
8.09.1 INTRODUCTION
8.09.2 MAGNITUDE OF THE PROBLEM INCIDENCE, DEATH RATES, AND GENDER DIFFERENCES
8.09.3 ETIOLOGY, RISK FACTORS, AND PREVENTION
8.09.4 PSYCHOLOGICAL, SOCIAL, AND BEHAVIORAL IMPACT OF CANCER
8.09.4.1 Symptom Appearance
8.09.4.2 Diagnosis
8.09.4.3 Treatment
8.09.4.3.1 Surgery
8.09.4.3.2 Radiotherapy
8.09.4.3.3 Chemotherapy
8.09.4.3.4 Bone marrow transplantation
8.09.4.3.5 Treatment side effects
8.09.4.3.6 Choosing cancer treatments
8.09.4.4 Recovery and Long-term Survival
8.09.4.5 Recurrence and Death
8.09.5 CONCLUSION
8.09.6 REFERENCES
8.09.1 INTRODUCTION
The cost of human lives to cancer (defined as
any malignant tumor; Rothenberg, 1992), is
overwhelming. In many countries cancer is the
second leading cause of death, only outnum-
bered by heart disease. In the USA alone, over
3500 people are diagnosed with cancer and
another 1500 people die from cancer-related
deaths per day (Parker, Tong, Bolden, & Wingo,
1997). While much of the increase in cancer
incidence and mortality over the years appears
related to advances in early detection as well as
the general aging of the population (age is a risk
factor; Garfinkel, 1994), Cunningham (1997)
has noted cancer death rates may now be
showing a downward trend in the USA. There
is, however, variability across countries. For
example, age-adjusted death rates per 100 000
population across sites and gender for
217
217
218
218
220
220
221
222
223
223
223
224
225
226
227
229
231
232
1990±1993 ranged from 394 in Hungary to
139 in Albania; the rate for the USA is 276
(average: Parker et al., 1997). In short, cancer is
a significant medical problem that affects the
health status of millions of people worldwide.
Research on the psychological, social, and
behavioral aspects of oncology began in the
early 1950s; however, our knowledge base has
significantly expanded since the 1970s. In
particular, research has clarified relationships
between psychological responses (e.g., person-
ality, mood, coping style, relationships), social
factors (e.g., presence/absence of partner,
degree of social support), and behavioral
variables (e.g., compliance with treatment,
diet, exercise). More recent research has
incorporated biologic systems (e.g., immune
and endocrine), examining the interaction of
psychological, social, and behavioral variables
and their relationship to disease course (see
218 Cancer
Fawzy et al., 1993, for an example; see
Andersen, Kiecolt-Glaser, & Glaser, 1994,
for a discussion).
This chapter includes an overview of the
central findings on the psychological, social,
and behavioral impact of cancer. By way of
introduction, we begin by addressing the
magnitude of the cancer problem. Data on
cancer incidence, death rates, and gender
differences are highlighted. Where data from
the USA are used, it is noted that they represent
the same general trends found in other
industrialized, Western countries. Second, we
briefly discuss etiologic and risk factors and the
role of prevention. The largest section of the
chapter organizes research findings by disease
relevant time points, from symptom discovery
to recovery or death. Where appropriate,
specific intervention studies will be detailed.
Information about cancer's impact on a
patient's social network (spouse, family, etc.)
is also included. We conclude with a discussion
of psychological interventions and techniques
that appear to be effective in promoting
improved quality of life and coping in cancer
patients.
8.09.2 MAGNITUDE OF THE PROBLEM
INCIDENCE, DEATH RATES, AND
GENDER DIFFERENCES
Cancers vary in their prevalence and mortal-
ity. Tables 1 and 2 display data from the USA on
the incidence and death rates by specific sites
and genders. These data indicate, for example,
that the most common diagnosis for women is
breast cancer and for men, prostate cancer, but
that lung cancer is the number one killer for
both (Parker et al., 1997). Similarly, Tables 3
and 4 provide death rate data from selected
countries (Parker et al., 1997). These data
illustrate the geographic, nationality, and sex
differences that exist (e.g., lung cancer death
rates of 81.6 per 100 000 for Hungarian men, but
a rate of 5.2 for French women). In examining
the death rates worldwide, the top killers of
women include breast, colon and rectum, lung,
and stomach cancers. For men, lung, stomach,
colon and rectum, and prostate cancers are the
common killers worldwide.
8.09.3 ETIOLOGY, RISK FACTORS, AND
PREVENTION
The specific events that turn a normal cell into
a cancerous cell are still unknown (Rugo, 1993).
However, we do know that it takes generations
of mutations for cells to become cancerous. The
development of cancer within an individual
appears to depend on genetic or environmental
factors, with exposure to carcinogens often
playing a significant role in many cancers
(Rugo, 1993). In fact, cancer incidence and
concomitant premature death have been linked
to behavioral habits that increase exposure. In
the United States, for example, the National
Cancer Institute set a goal of a 50% reduction in
cancer mortality by the year 2000 through
prevention and control efforts focused, in large
part, on lifestyle (Greenwald & Cullen, 1985).
Primary prevention tactics have attempted
to reduce the probability of cancer onset by
decreasing exposure to risk factors. For women
and men, unhealthy habits have been a beha-
vioral research target, and smoking has been
emphasized, as it is related to 30% of all cancer
deaths (Rugo, 1993). Cigarette smoking is
directly linked to lung cancer, one of the leading
causes of death for men and women, and is
implicated in cancers of the larynx, head and
neck, esophagus, bladder, kidney, pancreas, and
stomach.
Other lifestyle behaviors that have been
linked to greater risk are dietary patterns and
sun exposure (e.g., ultraviolet light). Diet
research has suggested that diets high in fat
and low in fiber may contribute to increased
risk for particular cancers (e.g., breast and
colon, respectively). Recommendations for
modificationÐreductions in fat intake and
increases in complex carbohydrates and fiberÐ
and weight reduction per se have been
suggested (Ashley, 1993; Wynder & Cohen,
1993). In breast cancer prevention, for exam-
ple, interventions have been developed for at-
risk women to reduce weight and fat intake and
to increase physical activity (Heber, Bagga,
Ashley, & Elashloff, 1993). Parallel interven-
tions focused on increasing fiber in the diet
may be important for decreasing one's risk for
gastrointestinal cancers. Concerning sun ex-
posure, the number of people diagnosed with
skin cancers has been steadily increasing over
recent years. In fact, close to 1 million
diagnoses of basal and squamous cell skin
cancers are expected in 1997 and this figure
does not include malignant melanoma (Parker
et al., 1997). It has been recommended that
time spent exposed to the sun, especially during
the hottest part of the day, be decreased and
the use of lotions that block exposure to
harmful ultraviolet rays be used. Another risk
factor involves exposure to certain viruses. The
human papilloma virus has been linked to
gynecologic cancers and the human immuno-
deficiency virus has been associated to non-
Hodgkin's lymphoma and Kaposi's sarcoma.
Prevention efforts have focused on safer sexual
practices with barrier methods (e.g., diaphram,
 Etiology, Risk Factors, and Prevention 219

Table 1 1997 estimates of cancer incidence by site and gender for the five leading sites.

Male (total estimated 785 800) Female (total estimated 506 000)

Site Number (%) Site Number (%)

Prostate 334 500 (43) Breast 180 200 (30)

Lung 98 300 (13) Colon/rectum 79 800 (13)
Colon/rectum 48 100 (8) Lung 50 900 (11)
Bladder 39 500 (5) Uterus 34 900 (6)
Lymphoma 30 300 (4) Ovary 26 800 (4)

Adapted from Cancer Statistics Ð 1997, American Cancer Society.

Table 2 1997 estimates of cancer mortality by site and gender for the five leading sites.

Male (total estimated 294 100) Female (total estimated 265 900)

Site Number (%) Site Number (%)

Lung 94 400 (32) Lung 66 000 (25)

Prostate 41 800 (14) Breast 43 900 (17)
Colon/rectum 27 000 (9) Colon/rectum 27 900 (10)
Pancreas 13 500 (5) Pancrease 14 600 (5)
Lymphoma 12 400 (4) Ovary 14 200 (5)

Adapted from Cancer Statistics Ð 1997, American Cancer Society.

Table 3 Age-adjusted death rates in adult males per 100 000 for selected countries and
disease sites for 1990±1993.

Country All sites Colon/rectum Lung Prostate Stomach

USA 165.3 (27) 16.5 57.1 17.5 5.0

Hungary 258.7 (1) 38.0 81.6 15.8 23.4
Poland 204.2 (8) 15.4 71.3 9.9 21.6
Italy 189.2 (15) 15.3 57.0 11.6 16.9
New Zealand 170.6 (21) 26.4 42.6 19.0 9.0
Finland 149.9 (31) 12.4 46.1 18.3 11.5
Israel 116.9 (43) 15.3 25.7 9.2 8.7
Mexico 81.6 (48) 3.3 15.9 10.6 9.9

Figures in parentheses are order of rank based on data from 48 countries during the years 1990±1993. Adapted from
Parker et al. (1997).

Table 4 Age-adjusted death rates in Adult females per 100 000 for selected countries and
disease sites for 1990±1993.

Country All sites Colon/rectum Lung Prostate Stomach

USA 111.1 (8) 22.0 11.2 25.6 2.3

Denmark 138.7 (1) 27.2 17.2 24.8 3.9
Austria 105.6 (16) 21.8 13.7 9.3 7.8
Russian Fed. 99.9 (21) 14.9 12.3 7.3 16.9
Argentina 96.4 (27) 21.3 9.2 6.0 4.8
France 86.5 (36) 19.7 10.1 5.2 3.3
Japan 75.2 (43) 6.6 9.8 8.1 14.2
Albania 42.7 (48) 5.2 2.2 5.0 6.3

Figures in parentheses are order of rank based on data from 48 countries during the years 1990±1993. Adapted from
Parker et al. (1997).
220 Cancer
use of condoms). Additionally, a family history
of cancer may double a person's risk for that
same cancer. For example, in breast cancer, the
greater the number of affected relatives and the
younger these relatives were at the time of
diagnosis, the higher a woman's risk. Women
with multiple first-degree relatives (e.g.,
mother, sisters) with premenopausal breast
cancer are at highest risk. In such families,
breast cancer appears to be transmitted as a
gene, and the risk of breast cancer may
approach 80%. New evidence is also emerging
on a gene associated with the development of
prostate cancer.
Secondary prevention efforts have been
defined as those that identify the disease at
the earliest of stages (e.g., when it is preinvasive
or localized and asymptomatic) so that effective
treatment can be administered sooner and
mortality reduced. The chances of successful
early cancer detection and treatment depend
upon the clinical characteristics of the disease
and the screening strategy, and it is unlikely that
secondary prevention can proceed effectively
unless certain conditions for both are met.
Behavioral scientists have focused mainly on
the early detection of breast cancer, especially
with mammography (the most reliable means of
early detection). Investigators (e.g., Rimer,
1992) have considered the psychological, beha-
vioral, sociodemographic, and healthcare fac-
tors that appear to be related to women's usage
of mammography. Older women, poorer wo-
men, and those with weak linkages to the
healthcare system, for example, are less frequent
users of mammography. Factors such as these
result in deadly consequences for women, as
poorer or older women without a history of
mammography are often diagnosed with more
advanced disease. Thus, to the extent that
behavioral scientists can affect women's accep-
tance and utilization of the technique, survival
may be directly improved. Early detection
efforts have also focused on prostate, skin,
and colorectal cancers with behavioral scientists
finally beginning to study prostate cancer.
8.09.4 PSYCHOLOGICAL, SOCIAL, AND
BEHAVIORAL IMPACT OF
CANCER
8.09.4.1 Symptom Appearance
In the study of delay in seeking treatment for
medical conditions, several definitions of delay
have been used, but an oft-chosen operationa-
lization is the number of days from the detection
of the first symptom to an end point. This latter
variable is less consistently chosen, but has
included seeing a physician for symptoms (e.g.,
Coates et al., 1992; Waters, Nichols, Wheeler,
Fraser, & Hayes, 1983), being diagnosed with a
medical condition (Marshall, Gregorio, &
Walsh, 1982), or beginning treatment for the
condition (e.g., Howson, 1950). According to
this view, all individuals, and even some
physicians, would be ªdelayers.º Still another
strategy has been to designate some delay as
more ªreasonableº than others (e.g., one month
from symptom appearance to appearance
before a physician; see early work in cancer
by Pack & Gallo, 1938).
Andersen and Cacioppo (1995) have con-
ceived of delay as comprising a series of stages
(e.g., appraisal, illness, behavioral, scheduling)
each governed by a conceptually distinct set of
decisional and appraisal processes. Appraisal
delay, delay surrounding symptom interpreta-
tion, has been found to account for most of the
delay in seeking a cancer diagnosis (see
Andersen & Cacioppo, 1995, for a model of
delay). For example, the appraisal interval was
approximately 80% of the total delay for
women with gynecologic cancer, whereas for
women with breast symptoms, a site that has a
narrower range of symptom diversity, the
interval accounted for 60% of the delay.
It is likely that there are several reasons for
the finding of appraisal processes accounting for
the bulk of the delay time. First, the develop-
ment of malignancy and the appearance of
cancer symptoms are protracted, and a complex
and changing symptom picture can be typical,
unlike the presentation of many other medical
problems (e.g., myocardial infarction; see
Matthews, Siegel, Kuller, Thompson, & Varat,
1983). Symptoms can also vary with the site and
extent of the disease. For example, ovarian
cancer has varied presentationsÐpelvic cramp-
ing, low back pain, pain or bleeding with
intercourse, urinary frequency irregularities.
Moreover, as cancers progress, they can involve
other bodily systems (e.g., gastrointestinal,
lymphatic) and the symptom picture tends to
change from specific or localized complaints
(e.g., vaginal discharge/bleeding) to diffuse ones
(e.g., loss of appetite, nausea, flu symptoms).
Finally, cancer is a life-threatening disease but a
low probability disease for many, and thus the
appraisal process may lengthen.
Briefly considering the other stages, illness
delay is defined as the number of days elapsing
from the time an individual concludes he or she
is ill to the day he or she decides to seek medical
help. At this time individuals must decide, for
example, whether to seek assistance from others
(e.g., physician, others with a similar condition)
or to self-treat the illness. After this, the delay is
spent in making two remaining decisions. One is
the delay between the decision to seek medical
 Psychological, Social, and Behavioral Impact of Cancer
attention and the person acting on this decision
by making an appointment (behavioral delay).
The other is the time that elapses between the
person making an appointment and his or her
first receipt of medical attention (scheduling
delay). Economic factors such as affordability,
social factors such as family influence, and
cognitive factors such as the extent to which the
decision to seek medical help is based on issue-
relevant thinking are more likely to modulate
the delay time between a decision to seek and an
action to receive medical care (behavioral
delay). In contrast, both patient characteristics
(such as the manner in which the person
describes his or her concerns and symptoms)
and medical environment characteristics (such
as a physician's appointment backlog), which
are not under an individual's control, may
modulate the delay incurred when scheduling an
appointment. Therefore, shortening delay to
seeking a diagnosis once symptom/sign aware-
ness has occurred (tertiary prevention) would
improve survival, as early detection is linked to
improved survival rates for many sites (e.g.,
cervix, breast, colon, prostate).
8.09.4.2 Diagnosis
An early clinical study suggested that the
diagnosis of cancer produces an ªexistential
plight,º meaning that the news brings shock,
disbelief, and emotional turmoil (Weisman &
Worden, 1976). Today, we know that indivi-
duals even become alarmed at the time of
medical screening, long before a cancer diag-
nosis is suggested (Wardle & Pope, 1992).
Perhaps because of these natural, difficult
reactions, over the years there has been some
variability in whether or not patients were told
that their diagnosis was cancer.
In the USA as well as most Western countries,
patients (including children) are now told that
their diagnosis is cancer, since this is regarded as
the moral, ethical, and legal procedure to follow
(Woodard & Pamies, 1992). Support of this
policy has documented the beneficial effects of
coping successfully with an extreme stressor
such as cancer (Taylor, 1983), and follow-up
studies of childhood leukemia survivors, for
example, have pointed toward more favorable
long-term adjustment for children when they
learn of their diagnosis early, whether directly,
accidentally, or through their own efforts, in
comparison with children who learn late
(Slavin, O'Malley, Koocher, & Foster, 1982).
Likewise, Mosconi, Meyerowitz, Liberati and
Liberati (1991) found that of 1171 Italian breast
cancer patients, those who were told their
diagnosis was cancer were more satisfied with
the information they had received from their
221
physicians. Still other cross-cultural research
has indicated that the majority of patients want
to be told their diagnosis truthfully (e.g., Japan,
Mizushima et al., 1990; UK, Sell et al., 1993).
Further, the manner in which the information is
disclosed is important. Physicians who com-
municate hope have patients who are more
hopeful, more favorable towards their cancer
diagnosis, and who report more favorable
overall emotional adjustment (Sardell & Trier-
weiler, 1993). This points to the need of
physicians and other health professionals to
learn more effective and thorough means of
communicating information (e.g., diagnosis,
treatment, prognosis) to their patients (Sell
et al., Woodard & Pamies, 1992).
Empirical reports clarify the specific
emotionsÐsadness (depression), fear (anxiety),
and angerÐthat characterize this period. It is
not surprising that depression is the most
common affective problem. Survey estimates
for major depression are of the order of 5±6%
(Derogatis et al., 1983; Lansky et al., 1985),
similar to that of the general population (Locke
& Regier, 1985). However, when major depres-
sion and depressed mood are considered,
prevalence rates are higher (e.g., 16% in
Derogatis et al., 1983; 25% in a review by
Massie & Holland, 1990). Lower rates have been
found when specified diagnostic criteria are used
and/or the patients assessed are ambulatory
with good physical functioning (Levin, Jones, &
Sack, 1993; Massie & Holland, 1990). In
general, depression is more common for those
patients in active treatment rather than those on
follow-up, receiving palliative rather than
curative treatment, with pain or other disturbing
symptoms rather than not, and/or with a history
of affective disorder or alcoholism.
Study of the psychological responses that
characterize the response to cancer diagnosis
may shed light on the reactions of individuals to
other life-threatening disease or treatment
circumstances. In fact, when moods (Cassileth
et al., 1985; Westbrook & Viney, 1982) or
coping strategies (Felton, Revenson, & Hin-
richsen, 1984) have been compared across
disease groups (e.g., rheumatoid arthritis,
diabetes, cancer, renal disease, hypertension),
few differences have been found, suggesting that
cancer patients may respond similarly to those
with other life-threatening and/or chronic
illnesses. On the other hand, patients in these
early studies were heterogeneous on many
disease variables (e.g., time since diagnosis,
active treatment vs. follow-up status, and/or
disability) that are important predictors of
differential responses among cancer patients.
Differences in the patterns of emotional
distress may exist. For example, it has been
222
suggested that breast and gynecological cancer
patients are significantly less depressed, an-
xious, and hostile (angry) possibly due to
perceptions of their illness as less serious than
women with other forms of cancer (e.g., lung,
gastrointestinal, head and neck; Sneed, Edlund,
& Dias, 1992). Similarly, a comparison of
patients with limited vs. extensive lung cancer
and equivalent levels of physical impairment
found that significantly greater mood distur-
bance was reported by the patients with
extensive disease and poorer prognoses (Cella
et al., 1987). Related findings have emerged for
individuals who perceive their illness as severe
(Marks, Richardson, Graham, & Levine, 1986)
or who have a sense of pessimism about their life
(Carver et al., 1994). In fact, Carver et al. found
that general pessimism (vs. optimism) at
diagnosis predicted poorer well-being (mood
and life satisfaction) at one day before surgery
as well as at 3, 6, and 12 month follow-ups. In
addition, when patients are followed long-
itudinally, the emotional responses at recur-
rence are characterized by significantly higher
levels of depression and anger than had been
reported at the time of initial diagnosis
(Andersen, Anderson, & deProsse, 1989b).
It is encouraging that the clinical problem of
diagnostic and treatment-related distress can be
alleviated through psychological interventions
(see Andersen, 1992, for a review). A compre-
hensive example of such an effort is the study of
Fawzy, Cousins et al. (1990) and Fawzy,
Kemeny et al. (1990). They attempted to reduce
distress and enhance immune functioning in
newly diagnosed melanoma patients via a
structured group support intervention which
included health education, illness-related pro-
blem solving, relaxation training, and group
support. The format was weekly group treat-
ment for six sessions. Eighty patients with early
stage melanoma participated and were rando-
mized to intervention or control conditions. The
post-treatment analyses indicated that the
intervention subjects reported significantly
more vigor, but there were no other emotional
distress differences. By six months, emotional
distress had improved for the intervention
subjects with significantly lower depression,
confusion, and fatigue, and higher vigor. Coping
data indicated that the intervention subjects
reported significantly more use of active-
behavioral strategies by the treatment's end, a
pattern that continued with the addition of
active-cognitive strategies by six months. Re-
garding the immunologic findings, at six months
there was a significant difference in groups with
better immunologic status for the intervention
subjects. These data are impressive in that they
suggest that improvements in psychological
Cancer
status and coping are associated with changes
(upregulation) in immune responses.
Improvements such as these in mood and
coping are all the more impressive because they
are often achieved with brief, cost-effective
interventions (e.g., 10 therapy hours with
delivery in a group format; Andersen, 1992).
Studies that have provided follow-up data also
suggest some consolidation of intervention
effects across time (upwards of six months
post-treatment), with lowered emotional dis-
tress, enhanced coping, and/or improved sexual
functioning (e.g., Capone, Good, Westie, &
Jacobson, 1980; Christensen, 1983).
8.09.4.3 Treatment
A certain component of the emotional
distress occurring at diagnosis is due to the
anticipation of treatment. Current therapies
include surgery, radiotherapy and radioactive
substances, chemotherapy, hormonal therapy,
immunotherapy, and combination regimens
and procedures (e.g., bone marrow transplanta-
tion, intraoperative radiotherapy). Some pa-
tients also undergo difficult diagnostic or
treatment monitoring procedures (e.g., bone
marrow aspirations), and all treatments are
preceded or followed by physical examinations,
tumor surveys, and/or laboratory studies. Thus,
the diagnostic process of selecting the appro-
priate therapy and subsequent treatment events
can represent multiple medical stressors. As will
be discussed below, the data are consistent in
their portrayal of more distress (particularly
fear and anxiety), slower rates of emotional
recovery, and, perhaps, higher rates of other
behavioral difficulties (e.g., food aversions,
continued fatigue and malaise) in cancer
patients compared with healthy individuals
undergoing noncancer-related medical treat-
ment. The emotional crisis that characterizes the
diagnostic period lessens as time passes, and
longitudinal studies find that as treatments end
and recovery begins there is an emotional
rebound (e.g., Andersen et al., 1989b; Bloom,
1987; Devlen, Maguire, Phillips, Crowther, &
Chambers, 1987; Edgar, Rosberger, & Nowlis,
1992). This lowering of emotional distress over
time is found even for patients undergoing
radical treatment requiring major adjustments
(e.g., radical neck dissection with laryngectomy;
Manuel, Roth, Keefe, & Brantley, 1987). As
cancer treatments (surgery, radiation, etc.) vary
considerably in their intent, morbidity, and
mortality, we will review each of the major
modalities separately and also discuss three
clinical problemsÐcompliance, appetite and
weight loss, and fatigueÐthat are common
across therapies.
 Psychological, Social, and Behavioral Impact of Cancer
8.09.4.3.1 Surgery
There have been few investigations of cancer
surgery, but there are numerous descriptive
and intervention studies of the reactions of
healthy individuals undergoing surgery for
benign conditions. The latter studies are
consistent in their portrayal of (i) high levels
of self-reported preoperative anxiety predictive
of higher postoperative anxiety, and (ii) higher
postoperative anxiety predictive of longer
recovery (e.g., decreased time out of bed,
increased pain reports). What may distinguish
cancer surgery patients are higher overall levels
of distress and slower rates of emotional
recovery. For example, Gottesman and Lewis
(1982) found greater and more lasting feelings
of crisis and helplessness among cancer
patients in comparison to benign surgery
patients for as long as two months following
discharge.
Considering these data, findings on the
interaction patterns of physicians and cancer
patients on morning surgical rounds is disturb-
ing. Blanchard, Ruckdeschel, Labrecque,
Frisch, and Blanchard (1987) found attending
physicians on a cancer unit less likely to be
supportive and to address patientsº needs than
physicians treating general medical patients.
The heavier volume and more seriously ill
patients common to cancer units might be
sources for this unfortunate relationship. Re-
lated findings indicate that oncology nurses
might find their job significantly more stressful
than other taxing assignments (e.g., cardiac,
intensive care, or operating room; Stewart,
Meyerowitz, Jackson, Yarkin, & Harvey, 1982),
and may limit their communication with cancer
patients, especially those experiencing a recur-
rence (Wilkinson, 1991).
As noted above, there has been considerable
research on the psychological and behavioral
aspects of response to surgery, and many
effective interventions have been tested. Com-
ponents of these interventions include proce-
dural information (e.g., how the surgery is to
be performed as well as pre- and postoperative
events from the perspective of the patient),
sensory information on the actual physical
sensations of the surgery or preparatory events,
behavioral coping instructions, cognitive cop-
ing interventions, relaxation, hypnosis, and
emotion-focused interventions. In a meta-
analysis of this literature, Johnston and Vogele
(1993) reported that procedural information
and behavioral instructions show consistent
and strong positive effects on postoperative
recovery. Effects are significant for a broad
band of measures, including ratings of negative
affect and pain, amount of pain medication,
223
length of stay, behavioral recovery, and
physiological indices.
8.09.4.3.2 Radiotherapy
At least 350 000 individuals in the USA
receive radiation therapy each year. Clinical
descriptions have noted patientsº fears (e.g.,
being burned, hair loss, sterility); while such
outcomes do occur, they are site- and dosage-
dependent. To understand radiation fears, the
surgical anxiety studies already described above
have been used as a research paradigm. Here,
again, anxiety (and sleeplessness) can often
cause more overall distress than physical
symptoms (Munro, Biruls, Griffin, Thomas,
& Vallis, 1989), and are predictors of treatment
response (Wallace, Priestman, Dunn, & Priest-
man, 1993). If interventions to reduce distress
(especially anticipatory anxiety) are not con-
ducted, heightened post-treatment anxiety is
also found (Andersen, Karlsson, Anderson, &
Tewfik, 1984; Andersen & Tewfik, 1985) and
might be maintained for as long as three months
post-therapy, particularly when treatment
symptoms linger (e.g., diarrhea, fatigue; King,
Nail, Kreamer, Strohl, & Johnson, 1985). When
acute side effects resolve (usually by 12 months
post-treatment), there appears to be no higher
incidence of emotional difficulties for radio-
therapy patients than for cancer surgery
patients (Hughson, Cooper, McArdle, & Smith,
1987).
8.09.4.3.3 Chemotherapy
Of all the treatment modalities, the greatest
progress has been in the understanding of
psychological reactions to chemotherapy and
the related toxicities, particularly nausea and
vomiting. Over a decade of research has
revealed that approximately 60% of cancer
patients will develop nausea and another 50%
will develop vomiting in response to cytotoxic
treatments (Morrow & Hickok, 1993). Psycho-
logical research has focused on eliminating or
reducing these problems through hypnosis (e.g.,
Redd, Andersen, & Minagawa, 1982), progres-
sive muscle relaxation with guided imagery
(e.g., Burish & Jenkins, 1992; Carey & Burish,
1988), systematic desensitization (e.g., Morrow
et al., 1992), cognitive distraction (e.g., Greene,
Seime, & Smith, 1991; Vasterling, Jenkins,
Tope, & Burish, 1993), and biofeedback (e.g.,
Burish & Jenkins).
The routine use of antiemetic and antianxiety
drugs and the development of newer chemother-
apeutic agents has resulted in an overall lower
incidence and clinical severity of nausea and
vomiting. However, the above gains may be
224 Cancer
somewhat offset by the more current medical
practice of using dose-intensive regimens as well
as treating disease types or stages not previously
given adjuvant chemotherapy (Andrykowski,
1993). It is clear that pretreatment with
medications can control nausea and thus reduce
vomiting, but pretreatment can also reduce the
likelihood of anticipatory reactions. Anticipa-
tory reactions are believed to be conditioned
responses resulting from the learning process of
classical conditioning in which side effects (e.g.
nausea and vomiting) become associated with
previously neutral stimuli (driving to the
hospital, sitting in the waiting room, etc.). Once
anticipatory nausea and vomiting develops,
antiemetics are less effective, and it has been
suggested that behavioral strategies should be
used to aid patients (Andrykowski, 1993;
Morrow & Hickok, 1993; Redd, 1993). Other
research that may be helpful includes identifying
the characteristics of individuals (e.g., high
pretreatment anxiety or autonomic activity;
severity of post-treatment vomiting in the early
cycles; age; susceptibility to motion sickness or
gastrointestinal distress), as well as character-
istics of the agents (e.g., rated emetogenic
potential of the regimen, dosages, rate of
infusion) that place patients at risk of the
development of nausea and vomiting (see Carey
& Burish, 1988, or Morrow, 1986, for empirical
tests of variables; see Morrow & Hickok, 1993,
for a review of the potential variables).
8.09.4.3.4 Bone marrow transplantation
Over the past two decades, bone marrow
transplantation (BMT) has evolved from an
experimental procedure performed only when
conventional therapies have failed (e.g., recur-
rent breast cancer) to an effective therapy
considered as an alternative worthy of study
in clinical trials as a first-line therapy (Baker,
Curbow, & Wingard, 1991). It was initially used
only for those with lymphohematopoietic
malignancies or disorders characterized by bone
marrow failure (e.g., leukemia, Hodgkin's
disease, and non-Hodgkin's lymphoma; Win-
gard, Curbow, Baker, & Piantadosi, 1991), but
is now being used with a variety of solid tumors
(e.g., neuroblastomas, germ cell tumors, and
cancers of the breast and ovary). The rapid
acceptance and expanded use of this toxic
modality is no less than dramatic. For example,
a Phase II study has begun in the USA for BMT
as an adjuvant treatment for breast cancer
patients with 10 or more positive lymph nodes
(Winer & Sutton, 1994). If beneficial, it is
possible that thousands of breast cancer
patients may undergo BMT as a standard
treatment for metastatic as well as regional
disease in the near future (Winer & Sutton,
1994). At present it is estimated that there are
over 5000 transplants performed each year
worldwide (Alby, 1991).
BMT is a complex and potentially fatal
treatment. The target of the treatment, the bone
marrow, is destroyed with high dose chemother-
apy, with or without whole body radiation
afterwards. The bone marrow to be trans-
planted comes from a donor (allogenic BMT) or
from the patient (autologous BMT) after it has
been removed and treated. Although allogenic
BMT has a role, its expansion is limited by the
need for a suitable donor and the subsequent
risk of graft vs. host disease for the patient. In
the case of autologous BMT, a variety of ex vivo
procedures are used to destroy the malignant
cells in the patient's marrow prior to reinfusion,
including treatment with cytotoxic drugs,
exposure to monoclonal antibodies that will
attack tumor-associated antigens, or harvesting
and introducing stem cells (cells from peripheral
blood).
Patients (and their families) are faced with a
number of stressors: a life-threatening illness,
location of a suitable donor (for allogeneic
transplants see Alby, 1991; Patenaude, 1990), a
toxic treatment, and common and potentially
fatal side effects (e.g., liver failure). There are
many acute side effects as well (e.g., hair loss,
mouth and gastrointestinal mucositis, inferti-
lity, skin breakdown, infection, pneumonia).
Hospitalization is prolonged (often three to six
weeks or longer) and it is generally spent in
isolation (Alby, 1991; Baker et al., 1991; Winer
& Sutton, 1994). Of course, in the end, the
treatment can fail and the cancer persist or
rapidly recur (Patenaude, 1990; Winer &
Sutton, 1994).
The many difficultiesÐtoxicity, uncertainty,
illness and isolation, dependency, constant need
for care, expenseÐall contribute to patients
feeling out of control (helplessness), alone,
anxious, and/or depressed (Alby, 1991; Altma-
ier, Gingrich, & Fyfe, 1991; Brown & Kelly,
1976). In attempting to cope, patients may be
demanding, or the converse, withdrawn (Brown
& Kelly, 1976; Patenaude, 1990). Psychological
efforts have focused on providing support to
patients, their families, and staff (Alby, 1991),
and maximizing control for patients, such as
making choices about the hospital environment
whenever possible (Patenaude, 1990). For
example, BMT rooms are often equipped with
televisions/radios and weights and/or bicycles
are provided for exercise as patients become
stronger. Additionally, patients have been
encouraged to bring personal items from home
(e.g., pictures, photographs) to decorate their
rooms. Increased medical complications, age,
 Psychological, Social, and Behavioral Impact of Cancer
distance from home, and poorer pretransplant
psychosocial adjustment are associated with the
need for more intensive psychological consulta-
tion (Futterman, Wellisch, Bond, & Carr,
1991).
8.09.4.3.5 Treatment side effects
Important steps have also been made toward
understanding the etiology and prevention of at
least three common disease/treatment-related
complications. First, appetite and weight loss
are significant clinical problems for cancer
patients susceptible to tumor-induced metabo-
lism or taste changes, having tumor-related
obstructions (often diagnosed as primary ca-
chexia/anorexia), or receiving gastrointestinal-
toxic chemotherapy or abdominal radiotherapy
(secondary cachexia/anorexia). Malnutrition is
associated with increased morbidity and mor-
tality (Knox, 1991). Approximately 50% of the
above patients will develop food aversions, and
have two or three aversions to particular foods;
common aversions involve protein sources such
as meats, eggs, and dairy products (see Jacobson
& Schwartz, 1993, for a review). In particular,
learned food aversions due to chemotherapy
appear to be robust, with rapid acquisition
(usually after one to three treatments) and
maintenance after long delays (e.g., 48 hours)
between food intake and aversive reactions
(nausea) from the drugs (Bernstein, 1986;
Jacobson & Schwartz, 1993). Research in this
area has pointed the way, for example, to
interventions employing novel tastes or ªscape-
goatº foods (e.g., lemon-lime Kool-Aid, unu-
sually flavored hard candies such as coconut;
Jacobson & Schwart, 1993) to ªblockº con-
ditioning to familiar diet items, reducing food
and beverage intake prior to drug administra-
tion, and ingesting carbohydrate rather than
protein source meals. While food aversions may
not involve appetite or weight loss, patients may
unknowingly develop aversions to their favorite
foods and this can affect their daily routine and
perceived quality of life (Jacobson & Schwartz,
1993; Knox, 1991).
Second, fatigue is a problem reported by the
majority of patients receiving radio- or che-
motherapy (Nail & King, 1987; Smets, Garssen,
Schuster-Uitterhoeve, & deHaes, 1993). Fati-
gue, and related symptoms described by
patients as tiredness, lack of energy, sleepiness,
confusion, and poor concentration have been
related to cancer morbidity and poor treatment
compliance. Although a common experience,
few studies have been conducted on the
correlates of fatigue (see Irvine, Vincent,
Bubela, Thompson, & Graydon, 1991, for a
review; Pickard-Holley, 1991; see Smets et al.,
225
1993, for a review). Irvine et al. (1991) note that
research has not demonstrated consistent
relationships between fatigue, anemia, sleep-
lessness, and/or psychological distress (e.g.,
negative mood/depression), but it appears that
fatigue does reduce overall daily functioning.
Psychological and behavioral interventions
have focused on alleviating or increasing
tolerance to fatigue through preparatory in-
formation on side effects and activity±rest cycle
recommendations (e.g., naps in the afternoon;
Nail & King, 1987; Smets et al., 1993), as well as
other activity planning or coping efforts (e.g.,
planning/scheduling activities, decreasing non-
essential activities, and relying on others for
assistance as needed; Rhodes, Watson, &
Hanson, 1988).
The expectation and/or experience of un-
pleasant side effects can compromise a patient's
quality of life such that the patient may miss
treatment appointments and be unwilling or
unable to continue treatment, regardless of
whether it is curative or palliative (Morrow &
Hickok 1993; Richardson, Marks, & Levine,
1988). With noncompliance, the dosage of
treatment may be reduced, which can, in turn,
lower the cure rate. In short, noncompliance is a
behavioral problem that can have a direct
impact on the effectiveness of cancer therapy.
Noncompliance with treatment has been
related to increased emotional distress (e.g.,
Gilbar & Kaplan De-Nour, 1989; Richardson
et al., 1988), severity of treatment side effects
(e.g., nausea and vomiting, Lewis, Linet, &
Abeloff, 1983; Richardson et al., 1988), and
lower income (Lebovits et al., 1990). Even when
patients are responsible for self-administration
of therapy, such as taking their chemotherapy at
home in order to reduce the number of required,
but inconvenient, hospital visits, their noncom-
pliance may continue. One report of multidrug
therapy with adults having hematologic malig-
nancies indicated that self-reports (vs. sera
reports) overestimated compliance by a factor
of two (Richardson et al., 1987).
Psychological interventions have focused on
a variety of methods to improve patient
compliance, including appointment reminders,
clearly written and specific treatment commu-
nications (Anderson & Kirk, 1982), home visits,
and medication-taking shaping interventions
(Richardson et al., 1987), as well as hospital
interventions such as offering a tour of the
oncology clinic, videotape presentations about
the therapy, discussion/question sessions, and
take-home information (Burish, Snyder, &
Jenkins, 1991). Burish et al. and others (e.g.,
Nail & King, 1987; Rainey, 1985) suggest that
preparatory information can improve coping
with treatment.
226 Cancer
Importantly, psychological interventions can
reduce distress during and immediately follow-
ing cancer treatments. We now present the
findings from two illustrative studies. Cain,
Kohorn, Quinlan, Latimer, and Schwartz
(1986) compared individual and group therapy
formats with 72 women with recently diagnosed
gynecologic cancer or who were currently
receiving therapy for such a cancer. The
intervention had eight components including
discussion of the causes of cancer at diagnosis,
impact of the treatment(s) on body image and
sexuality, relaxation training, emphasis on
good dietary and exercise patterns, commu-
nication difficulties with medical staff and
friends/family, and setting goals for the future
to cope with uncertainty and fears of recur-
rence. The eight-session program was con-
ducted during individual sessions conducted in
the hospital or the woman's home or in weekly
groups of four to six patients conducted at the
hospital. Outcome measures were administered
pre- and post-treatment and at a six month
follow-up. Post-treatment analyses indicated all
groups improved with time; however, anxiety
was significantly lower for the individual
therapy subjects only. Gains for the interven-
tion subjects were more impressive with the six
month follow-up data when there were no
differences between the intervention formats,
but both groups reported less depression and
anxiety and better psychosocial adjustment
(including health perspectives, sexual function-
ing, and use of leisure time) than the no
treatment control group. Thus, the brief
intervention, delivered either in individual or
group format, appeared to be immediately
effective, with gains enhanced during the early
recovery months.
Edgar et al. (1992) provided a psychosocial
intervention to 205 patients who were rando-
mized into two groups: one group received the
intervention soon after entering the study and
the other group after a wait of four months.
The majority (n =159) of patients had been
diagnosed with breast, colon, lung, uterine, or
head and neck cancers. Both groups were
assessed on depression, anxiety, illness worry,
perceived personal control, and ego strength at
entry into the study, and at 4, 8, and 12 month
intervals. The intervention (comprising five
one-hour sessions) focused on coping skills and
included problem solving, goal setting, cogni-
tive reappraisal, relaxation training, and, at
four month intervals, workshops on healthcare
information and available resources. While
coping improved over the year for all patients,
the later intervention group experienced lower
levels of distress sooner than the group who had
received the intervention earlier. Edgar et al.
(1992) suggest that the delay in intervention
may have been beneficial because it afforded
patients the time to reduce feelings of being
overwhelmed and they were, therefore, more
ready to participate in the intervention.
Additionally, data indicated that patients with
lower ego strength and cancer diagnoses other
than breast cancer reported greater distress
and, therefore, particularly benefited from the
intervention, while patients with higher ego
strength tended to cope well regardless of the
intervention. These and related data (e.g.
Forester, Kornfield, & Fleiss, 1985; see An-
dersen, 1992, for a review) attest to the
significant distress that occurs when patients
are in the midst of coping with diagnosis and
treatment. Importantly, impressive gains can be
achieved by the end of the intervention and
often these positive gains are stronger with
continued follow-up. Again, these effects have
been achieved with brief interventions.
8.09.4.3.6 Choosing cancer treatments
Psychological and behavioral data have been
(and should continue to be) important to
patients and physicians alike for making
choices among comparable treatments. Treat-
ments that result in less quality of life
disruption often become standard treatment.
The most obvious example of the importance of
psychological data influencing cancer treat-
ments was that documenting the more positive
outcomes (e.g., feeling more attractive, fewer
sexual difficulties) for women treated with
breast-saving procedures (lumpectomy plus
adjuvant radiation and/or chemotherapy)
rather than modified radical mastectomy
(e.g., Margolis, Goodman, & Rubin, 1990).
Similarly, lower rates of erectile and ejaculation
difficulties (e.g., 30% vs. 90%) are important
reasons for some men to choose supervoltage
irradiation rather than surgery for prostate
cancer (radical prostatectomy; see Andersen &
Lamb, 1995, for a review). Parallel treatment
data are available for women with genital
cancer including those with uterine disease
(Andersen, Anderson, & deProsse, 1989a) or
preinvasive vulvar disease (Andersen, Turn-
quist, LaPolla, & Turner, 1988). Additionally,
Rathmell, Ash, Howes, and Nicholls (1991)
suggest that unless a survival advantage is
demonstrated, patients with advanced head and
neck cancer may want radiotherapy alone vs.
surgery plus radiotherapy, as the treatment
combination is associated with poorer quality
of life scores (e.g., psychological well-being,
speech quality, ability to eat, levels of energy
and activity).
 Psychological, Social, and Behavioral Impact of Cancer
8.09.4.4 Recovery and Long-term Survival
The most important cancer end points have
been treatment response rates, length of disease-
free interval, and survival. Yet, as the prognosis
for some sites has improved, there has been
increased attention to the quality of life,
particularly for long-term survivors of cancer.
The term ªsurvivorº typically refers to indivi-
duals surviving at least five years, as the
probability of late recurrence declines signifi-
cantly after that time for most sites. As
individuals recover and resume their life
patterns, there may be residual emotional
distress, with some difficulties which require
continued coping, and even the appearance of
still other problems (late sequelae). We will
discuss each of these circumstances, and provide
examples of both emotional and physical
challenges which may confront the cancer
survivor.
An investigation by Dunkel-Schetter, Fein-
stein, Taylor, and Falke (1992) sheds light on
the strategies cancer patients use as they recover
and resume their life activities. They studied
coping patterns of 603 cancer patients. Patient
diagnoses included breast cancer, gastrointest-
inal, circulatory or lymph, gynecological, and
respiratory cancers, as well as others. The
timing of the assessment ranged from initial
diagnosis to more than five years post-treat-
ment. Five coping patterns were identified:
seeking or using social support, focusing on
positive aspects, distancing, cognitive escape-
avoidance (e.g., fantasizing or wishful thinking
with fatalistic thoughts of poor outcomes), and
behavioral escape-avoidance (e.g., social with-
drawal, drug use). All patients used multiple
coping strategies, but distancing was the most
common. Unique patterns were found for
subgroups. For example, individuals who
viewed cancer as more stressful tended to use
cognitive and behavioral escape-avoidance
strategies, whereas patients reporting less dis-
tress relied on seeking or using social support,
focusing on the positive, and distancing. Data
such as these may have many uses, such as being
used to tailor psychological interventions to
patient subgroups (e.g., identifying those pa-
tients who are likely to use drugs/alcohol to
cope).
Lingering emotional distress from the trauma
of diagnosis, treatment, and, more generally,
life threat, may occur for a small subset, 5±10%,
of cancer patients. When pronounced, this
long-term distress has been likened to post-
traumatic stress disorder. In fact, having
residual distress from the diagnosis and treat-
ment of a life-threatening illness is included as
one of the circumstances which may precipitate
227
a Diagnostic and statistical manual of mental
disorders (American Psychiatric Association,
1994) diagnosis of post-traumatic stress dis-
order. It is unlikely that such extreme distress
occurs for the ªaverageº cancer patient, and
instead may only be a possibility for those who
have undergone the most difficult of treatment
regimens (e.g., BMT), multiple agent and/or
lengthy chemotherapy regimens, as might be
given to Stage III ovary patients, or those who
undergo life-altering and/or disfiguring cancer
treatments (e.g., limb amputations, pelvic
exenteration, laryngectomies). As is the case
with anxiety disorders, individuals with a prior
history of traumatic stress might also be at
heightened risk.
Secondly, some cancer survivors may need to
cope with the expected, but nevertheless
troubling, sequelae which may be consequences
of the disease or treatment and be permanent.
For example, coping with altered abilities (e.g.,
loss of natural speech following laryngectomy)
or changes in organ functions (e.g., infertility)
may require adjustment which demands new
behaviors or emotions. Others may have to cope
with losses (e.g., a sexual relationship that does
not include intercourse). Thirdly, late side
effects of cancer treatment, for example, a
bowel dysfunction that is traced to pelvic
radiotherapy, can occur and change health
status as well as impact mood and coping.
Despite these possibilities, longitudinal data
indicate that if the disease is controlled, by one
year post-treatment the severe distress of
diagnosis will have dissipated and emotions
will have stabilized. The first longitudinal
studies conducted in the UK for breast cancer
patients indicated that by 12 (Maguire et al.,
1978) and 24 months (Morris, Greer, & White,
1977) that approximately 20% of the patients
had problems with moderate to severe depres-
sion in comparison to 8% of benign disease
comparison subjects. However, controlled long-
itudinal studies of breast (Bloom, 1987; Vino-
kur, Threatt, Caplan, & Zimmerman, 1989) and
gynecologic (Andersen et al., 1989b) patients
conducted in the USA and replicated with data
from The Netherlands (deHaes, van Oostrom,
& Welvaart, 1986) have indicated no differences
between the levels of emotional distress of
women with cancer and either benign disease or
healthy comparison subjects. Similar declines
and lowered levels of distress have been found in
retrospective (Cella & Tross, 1986) and long-
itudinal (Devlen et al., 1987) studies of
Hodgkin's disease and non-Hodgkin's lympho-
ma patients. The consistency of findings for the
studies conducted during the 1980s is important
because it represents replications across site,
and, to some degree, treatment toxicity. In sum,
228 Cancer
we preface the remaining discussion by noting
that global adjustment problems do not occur
for the majority of cancer survivors; a more
likely scenario is the occurrence of problem
areas.
Irvine, Brown, Crooks, Roberts, and Browne
(1991) concluded in their review of survivorship
following breast cancer that few patients
experience long-term psychological distress,
yet 20±30% will experience loss of roles (e.g.,
employment), decreased functional abilities,
and problems with social relationships. Data
on the adjustment of BMT survivors reveal a
somewhat slower recovery (Syrajala, Chapko,
Vitaliano, Cummings, & Sullivan, 1993). Com-
parison of BMT survivors and other cancer
patients on maintenance chemotherapy indi-
cated that psychological functioning was satis-
factory for both groups when assessed three to
four years postdiagnosis (Altmaier et al., 1991).
However, when BMT patients were assessed
sooner (two or four years post-treatment), they
reported poorer physical functioning, greater
impaired personal functioning (e.g., need for
self-care assistance), and more relational pro-
blems (e.g., sexual difficulties) than individuals
on maintainence chemotherapy (Altmaier et al.,
1991). Also, there are data to suggest that there
may be some risk of neuropsychological
impairment from BMT procedures. Data from
Andrykowski et al. (1992) suggest impairments
in memory and higher cognitive processing,
which may be a sequela of BMT, per se, or prior
cancer treatments which precede BMT (e.g.,
cranial radiation, intrathecal chemotherapy).
The many difficult aspects of BMT noted above
(e.g., intensive chemotherapy, possible whole
body irradiation, long recovery time, isolation)
may account for this slowed and potentially
more problematic recovery (see Andrykowski,
1994; or Winer & Sutton, 1994 for a review).
Data suggest that sexuality may be one
dimension that is more likely to undergo
disruption than other major life areas. All
cancer patients with solid tumors (approxi-
mately 85% of adult patients) are vulnerable to
sexual dysfunction. Across sites, estimates range
from 10% (e.g., breast cancer patients treated
with lumpectomy), 70±90% (e.g., women with
vulva cancer treated with modified radical
vulvectomy), to 100% (e.g., men with prostate
cancer treated with radical prostatectomy), with
the distribution skewed toward greater levels of
disruption (see Andersen & Lamb, 1995, for a
review). Among the hematologic malignancies,
such as Hodgkin's disease, estimates are in
the range of 20% (Andersen & Lamb, 1995).
The data within treatment sites indicate that
disease and treatment factors are the primary
etiologies for sexual problems (e.g., gynecologic
complications associated with long-term adju-
vant tamoxifen therapy for breast cancer, Wolf
& Jordan, 1992; female androgen deficiency
syndrome resulting from cytotoxic agents and/
or bilateral salpingo-oophorectomies, Kaplan
& Owett, 1993). Controlled longitudinal studies
of breast cancer patients (Maguire et al., 1978;
Morris et al., 1977) and gynecologic cancer
patients (Andersen et al., 1989a) have indicated
that if sexual problems develop, they do so as
soon as intercourse resumes, and, if untreated,
they are unlikely to resolve (see Andersen &
Elliott, 1994, for a discussion).
In addition to medical contributors, we have
focused on identifying sexual relevant psycho-
logical factors in predicting risk for sexual
morbidity. Specifically, sexual self-schema (self-
concept) is a cognitive view about sexual aspects
of oneself; it is derived from past experience,
manifest in current experience, and it guides the
processing of domain-relevant social informa-
tion (Andersen & Cyranowski, 1994). The
concept includes two positive aspectsÐan
inclination to experience romantic/passionate
emotions and a behavioral openness to sexual
experiences and/or relationships; and a negative
aspectÐembarrassment and/or conservatismÐ
which appears to be a deterrent to sexual
expression. Using a measure developed for this
purpose, the predictive power of sexual schema
was examined in the context of risk for sexual
morbidity following gynecologic cancer. Con-
sistent with our definition of the construct, we
anticipated that women with a negative sexual
self-concept, in contrast to women with a
positive sexual self-concept, would be at greatest
risk for sexual difficulty. Negative sexual
schema women would be expected to have
more difficulties because they are, in general,
less romantic/passionate in their emotions, less
open to sexual experiences, and more likely to
have negative feelings about their sexuality.
In a field test of sexual schema in the
prediction of gynecologic cancer outcomes
(Andersen, Woods, & Copeland, 1997), we
assessed 62 women who were currently disease
free but who received treatment from six months
to five years previously for Stage I±II disease.
Comparison subjects included 68 women seek-
ing routine gynecologic care. Analysis of the
quality of life data replicated earlier prospective
longitudinal findings (Andersen, Andersen, &
de Prosse, 1989a)Ðspecifically, sexuality is the
major life area of disruption for the survivor.
For example, there were no differences between
the groups in the areas of mental health
(emotional distress, depression) or social func-
tioning. In contrast, a comparison between the
samples in terms of current sexual functioning
found significant differences, with the cancer
 Psychological, Social, and Behavioral Impact of Cancer
sample reporting lower levels of sexual beha-
vior, sexual responsiveness, and global evalua-
tions. We tested the utility of the schema
construct with the cancer sample in the
prediction of sexual responsiveness (e.g., desire,
excitement, orgasm, and resolution) and sexual
behavior (frequency of intercourse) with regres-
sion analyses. Sexual self-schema accounted for
a significant and large portion of the variance
(26%) in the prediction of current sexual
responsiveness.
The high incidence of sexual and fertility
disruption has, in part, been the reason for the
concern over marital disruption among adult
cancer patients. An early clinical study of
women receiving radical mastectomy noted
the realistic feelings of body disfigurement that
both the women and spouses would feelÐ
prompting sexual retreat, emotional estrange-
ment, and, not surprisingly, marital disruption
(Bard & Sutherland, 1952). Other concerns over
the marriage originate from analyses of the
interpersonal relationships, per se, (Wortman &
Dunkel-Schetter, 1979). Despite the emotional
distress and, for some, accompanying sexual
disruption that couples experience, data from
retrospective studies with comparison groups
(Cella & Tross, 1986) and from the controlled
longitudinal studies previously discussed indi-
cate that the majority of marriages remain intact
and satisfactory. These data are consistent with
prospective studies showing that, when health
problems arise for newly married couples, they
are not among those problems precipitant to
divorce (Bentler & Newcomb, 1978). However,
multicenter studies have indicated that young
survivors of childhood cancers are significantly
less likely to marry, and once married they may
be at greater risk for subfertility (Byrne et al.,
1985, 1988; Teeter, Holmes, Holmes, & Baker,
1987).
Yet, the cancer experience is stressful for
those closest to the patient (see Baider, Cooper,
& Kaplan De-Nour, 1996, for a review), and the
kin's distress may approach that of the patient's
(Baider & Kaplan De-Nour, 1988; Cassileth
et al., 1985). Family strain appears to be affected
by illness variables (e.g., prognosis, stage/
duration of illness, care-giving demands, pa-
tient's distress), family variables (e.g., age and
gender of family members, socioeconomic
status, other family stressors), and relational
variables (e.g., quality of marriage, marital
communication, family stage, and social sup-
port; see Sales, Schulz, & Biegel, 1992, for a
review). Those couples in which the wife/mother
has cancer and young children are still in the
home may be at heightened risk for relationship
difficulties (Vess, Moreland, & Schwebel, 1985).
In addition, Ell, Nishimoto, Mantell, and
229
Hamovitch (1988) found that those kin who
were functioning poorly (e.g., lower perceived
personal control, less adequate emotional
support from close others, and greater stress
unrelated to cancer) when the patient was
diagnosed, or who lost personal and social
resources during the patient's treatment and
recovery, tended to function poorly at follow-
up. In sum, a subset of partners and family
members appear to be at psychosocial risk. For
a review of strategies (focusing on information
and support) that have been used to assist
spouses of cancer patients cope with stress over
the illness course, see Northouse and Peters-
Golden (1993).
Finally, other, nonpsychological difficulties
may occur following cancer, and these problems
may have psychological concomitants (e.g., low
self-esteem, perceived worthlessness). For ex-
ample, it has been found that survivors of
childhood or adolescent cancer are at risk of
rejection from the armed services or college
entrance and have difficulty obtaining health
and life insurance (Teta et al., 1986). Job
discrimination and insurance difficulties have
also been reported by survivors of bone marrow
transplantation (Wingard et al., 1991).
There have been few interventions targeted
for cancer survivors per se. One such study was
that by Telch and Telch (1986). They compared
the effectiveness of coping skills instruction vs.
supportive therapy for a heterogeneous sample
of cancer patients on follow-up. An important
research design aspect was the screening of the
subjects, and only those with ªclear evidence of
psychological distressº were included in the
trial. Both interventions were offered in a group
format. Instruction in coping skills taught
cognitive, behavioral, and affective strategies
and included goal setting, self-monitoring, and
role playing. Relaxation training and stress
management skills were also included and
patients provided ratings of their home practice.
The group support intervention provided an
environment for patients to discuss concerns
but there was no specific agenda. Each group
met for six weeks. Forty-one cancer patients
completed the study. Analyses for the emotional
distress data indicated that the coping skills
group improved significantly across all mea-
sures, the support group improved on anxiety
and depression only, but the no treatment
control worsened and reported significantly
more mood distress.
8.09.4.5 Recurrence and Death
Cancer recurrence is devastating; the magni-
tude of distress is even greater than that found
230 Cancer
with the initial diagnosis (Mahon, Cella, &
Donovan, 1990; Thompson, Andersen, &
DePetrillo, 1992), and studies contrasting
cancer patients showing no evidence of disease
with those receiving palliative treatment (e.g.,
Cassileth et al., 1985) have reported the greatest
distress for those with disseminated disease
(Bloom, 1987). Patients recently told of their
cancer recurrence reported being less hopeful,
more discouraged, having increased thoughts of
death and dying as well as feelings of guilt and
regret about their previous treatment decisions.
In one study (Mahon et al., 1990), 45% of the
patients indicated that they perceived their
recurrence as ªpunishment.º Therefore, diffi-
cult decisions (e.g., beginning a regimen that
offers little chance for cure and has side effects
vs. no treatment) are made in a context of
extreme emotional distress and physical debil-
itation. However, the few studies of psycholo-
gical interventions for adult patients have
indicated that important emotional gains can
be achieved during terminal stages (Linn, Linn,
& Harris, 1982) and that children and adoles-
cents, as well as adults, can make independent
decisions about the continuation of therapy
when death is imminent (Nitschke et al., 1982).
At this time of significant emotional turmoil
and physical difficulty, psychological interven-
tions appear to enhance the quality of life. One
example is an investigation of a group support
intervention for women with breast cancer
conducted by Spiegel and colleagues (Spiegel
& Bloom, 1983; Spiegel, Bloom, & Yalom,
1981). Women were randomized to no treat-
ment or a group treatment intervention that
included discussion of death and dying, family
problems, communication problems with phy-
sicians, and living fully in the context of a
terminal illness. The intervention subjects were
also randomized a second time to two condi-
tions: no additional treatment or self-hypnosis
for pain problems (Spiegel & Bloom, 1983),
which was incorporated into the support group
format. All intervention groups met for weekly
meetings for one year, for a total of 75 therapy
hours. At the end of the first year the groups
formally ended, but members could continue to
meet as they wished or were able; some groups
lasted for an additional two years. Eighty-six
women, 50 intervention and 36 no treatment
control, with metastatic breast cancer and
referred to the intervention by their oncologist,
participated. Following random assignment,
there was subject loss (e.g., refusal, too weak,
death) with the study beginning with 34
intervention and 24 control participants; how-
ever, the survival data are reported for the
original sample of 86. Analyses indicated that
the intervention group reported significantly
fewer phobic responses and lower anxiety,
fatigue, and confusion and higher vigor than
the controls. These differences were evident at
all assessments but the magnitude increased
from 4 to 12 months. There was also a
significant decrease in the use of maladaptive
coping responses by the intervention group.
Regarding the findings from the hypnosis
substudy, women receiving hypnosis within the
group support intervention reported no change
in their pain sensations during the year, while
pain sensations significantly increased for the
other women in group support who did not
receive hypnosis. Similar findings were reported
for pain sufferingÐa slight decrease for the
women who also received hypnosis and a
significant increase in suffering for the remain-
ing intervention women. It is important to note
that pain sensation scores for both groups were,
however, significantly lower than those for the
no intervention controls, suggesting that the
hypnosis component provided an additive
analgesic effect to other group treatment
components. The most startling data from this
project were reported in a survival analysis
described at the beginning of the chapter. A
variety of follow-up analyses, controlling for
initial disease stage, days of radiotherapy, or use
of androgen or steroid treatments were con-
ducted and all indicated the same survival
differences favoring the intervention partici-
pants. Unlike other studies, interventions for
terminal patients tend to be intensive and
lengthy, such as ªseveral sessionsº or ªuntil
death.º
Finally, a frequent complication of dissemi-
nated disease is pain. Although it might be one
of the first symptoms of cancer or be present
when disease is localized, pain is more common
and less controllable for those with metastatic
disease (Ahles, Ruckdeschel, & Blanchard,
1984). Some 80% of patients with recurrent
cancer report moderate to severe pain compared
with 40% of earlier stage patients (see Ashburn
& Lipman, 1993, for a review). The major cause
of cancer pain, accounting for roughly 70% of
the cases is due to direct tumor involvement
(e.g., metastatic bone disease, nerve compres-
sion). Another 20±30% of cases are due to
medical therapy (e.g., postoperative pain,
radiation-induced pain). The remaining cases
are individuals with pain problems unrelated to
their cancer (e.g., osteoarthritis; Foley, 1985).
Thus, the pain experienced by cancer patients
can be any combination of acute malignant
pain, chronic malignant pain, and/or chronic
nonmalignant pain (Ashburn & Lipman, 1993).
As the pain experienced by each patient is
variable (e.g., type, duration, resting vs. active,
diagnosis/treatment factors), it is important
 Conclusion
that a pain assessment be completed before and
during implementation of treatment for pain
control (Ashburn & Lipman, 1993; Coyle,
Adlehardt, Foley, & Portenoy, 1990). Besides
pain-specific qualities and diagnostic/treatment
considerations, other factors are also important
in assessing the patient's experience of pain. For
instance, pain is associated with depression,
anxiety, and delirium (Massie & Holland, 1992),
and may increase suicidal ideation (Coyle et al.,
1990). If pain worsens or is difficult to control,
quality of life deteriorates and emotional
distress increases (Massie & Holland, 1992),
physical mobility may lower (Ashburn & Lip-
man, 1993), and social interactions may decline
(Strang & Qvarner, 1990).
The most difficult circumstance of pain
control is when chronic pain accompanies
disease progression. Treatment combinations
of antitumor therapy, anesthetic blocks, and
behavioral approaches are considered. Beha-
vioral research has focused on assessment
strategies (Daut, Cleeland, & Flanery, 1983;
Keefe, Brantley, Manuel, & Crisson, 1985) and
on pain reduction interventions, particularly
hypnosis, to reduce pain (Spiegel & Bloom,
1983). When palliative therapy is of little use
and/or brings further debilitation, psychologi-
cal interventions may provide support and pain
control and, secondarily, treat pain sequelae
(e.g., sleep disturbances, reduced appetite,
irritability).
8.09.5 CONCLUSION
Significant progress has been made in under-
standing the psychological, social, and beha-
vioral aspects of cancer. There has been
progress in prevention and control. Research
on smoking prevention and cessation addresses
the factor responsible for 30% of all cancer
deaths. Similar efforts to encourage participa-
tion in screening and early detection programs
for breast, cervix, skin, prostate, and colon and
rectum cancers may also improve mortality
rates.
More is known about the psychological
processes and reactions to the diagnosis and
treatment of cancer than is known about any
other chronic illness. Breast cancer patients (see
Glanz & Lerman, 1992, for a review) have been
well studied, but other disease sites, men, and
children, are becoming more commonly stu-
died. Future research will probably test the
generalizability of these descriptive data and
formulate general principles of adjustment to
illness. While providing estimates of the
magnitude of quality of life problems, these
data can be used for models that predict which
231
patients might be at greatest risk for adjustment
difficulties (see Andersen, 1996, for a discus-
sion). The latter is an important step toward
designing interventions tailored to the difficul-
ties and circumstances of cancer patients.
The mental health community emphasizes the
need to reduce stress and prevent deteriorations
in quality of life for those with cancer. The
importance of such efforts is underscored by
three contextual factors. One, the stability of
many cancer mortality rates, particularly those
with the highest incidence such as lung and
breast, makes it imperative that new, innovative
treatments be developed to improve survival
rates. Two, research has demonstrated that
psychological interventions result in significant
improvements in quality of life (see Andersen,
1992, for a review). Three, both qualitative
(Maier, Watkins, & Fleshner, 1994) and
quantitative (Herbert & Cohen, 1993a, 1993b)
summaries of the psychoneuroimmunology
literature conclude that psychological distress
and stressors (e.g., negative life events, both
acute and chronic) are reliably associated with
changesÐdownregulationÐin immunity. Thus,
addressing the mental health needs of those with
cancer will have important quality of life
benefits and the possibility is raised of positive
biologic (or health) consequences as well. Figure
1 provides a conceptual model of the psycho-
logical and behavioral factors and biologic
mechanisms by which disease or health out-
comes might be influenced. The majority of the
paths move in one causal direction. We have
discussed the importance of conceptual models
in guiding future intervention research and in
testing for any health benefits of psychological
interventions (see Andersen et al., 1994).
A growing literature on the use of psycho-
logical interventions to improve the cancer
patient's quality of life also exists (Andersen,
1992). The effectiveness of these interventions is
robust, as they have reduced distress and
enhanced the quality of life of many cancer
patients differing on disease stage as well as
disease site. Despite the challenges of studying
these patients, well-controlled investigations
have been conducted. Improvements in emo-
tional distress are found at the end of the
interventions with continued gains at follow-up.
In addition, change in other areasÐself-esteem/
concept, death perceptions, life satisfaction,
and/or locus of controlÐhave been found.
Important for quality of life, psychological
interventions could also lower or stabilize pain
reports. The positive outcomes for terminal
patients are notable considering their worsening
pain and/or increasing debilitation.
While there appear to be unique intervention
components for different phases of the disease,
232 Cancer
Cancer
Compliance
diagnosis and
treatment
CNS
innervation
Neuro-
Stress endocrine
Reduced Health
QoL behaviours
Figure 1 Theoretical model. A biobehavioral model of the psychological, behavioral, and biologic pathways
from cancer stressors to disease course. CNS = central nervous system. From Andersen et al. (1994).
there are some commonalities. Therapy com-
ponents have included: an emotionally suppor-
tive context to address fears and anxieties about
the disease, information about the disease and
treatment, behavioral coping strategies, cogni-
tive coping strategies, and relaxation training to
lower ªarousalº and/or enhance one's sense of
control. The descriptive data also highlight the
need for focused interventions for sexual
functioning, particularly those treated for
gynecologic, breast, and prostate cancer, and
the intervention studies attest to the effective-
ness of these specific components. These various
components appear more important to outcome
than procedural variations. For example,
therapy format, such as individual or group,
appears to have little impact. Also, there were
null findings for (group) interventions that
included no structured content, suggesting that
group support alone is insufficient to produce
any measurable benefit (see Helgeson & Cohen,
1996, for a review).
How do psychological interventions achieve
these effects? In large measure, the psychologic
mechanisms may not be different from those
operative in interventions designed for coping
with other stressors. That is, confronting a
traumatic stressor with positive cognitive states,
active behavioral strategies and, eventually,
lowered emotional distress may enhance one's
sense of self-efficacy, feelings of control, and
provide realistic stress appraisals of the disease
or treatment process. Similarly for sexual
interventions, information provides realistic
expectations for sexuality and specific strategies
to manage sexual activity when it is difficult or
impossible. That the interventions produce
Disease:
Local
Immunity Disease
course
Disease:
metastatic
more than situational improvement and may
alter an individual's longer-term adjustment
processes is suggested by data indicating that
adjustment gains continue (and often increase)
during the first post-treatment year. Immediate
and longer-term psychologic changes may, in
turn, increase the likelihood of changes in
behavioral mechanisms, such as increasing the
likelihood of adaptive health behaviors (com-
plying with medical therapy; improving diet,
exercise, etc.), to improving mental health
directly, ªadjustmentº and, possibly, medical
outcomes (e.g., disease-free interval). These
data indicate that, increasingly, issues of quality
of life are being raised, and positive results have
been achieved by the behavioral scieces. But as
with most issues, further commitment and
action are needed.
8.09.6 REFERENCES
Ahles, T. A., Ruckdeschel, J. C., & Blanchard, E. B. (1984).
Cancer related pain. I. Prevalence in an outpatient
setting as a function of stage of disease and type of
cancer. Journal of Psychosomatic Research, 28, 115±119.
Alby, N. (1991). Leukaemia: Bone marrow transplantation.
In M. Watson (Ed.), Cancer patient care: Psychosocial
treatment methods (pp. 281±297). Cambridge, UK: BPS
Books.
Altmaier, E. M., Gingrich, R. D., & Fyfe, M. A. (1991).
Two-year adjustment of bone marrow transplant survi-
vors. Bone Marrow Transplantation, 7, 311±316.
American Cancer Society (1994). Cancer facts and
figuresÐ1994. Atlanta, CA: Author.
American Psychiatric Association (1994). Diagnostic and
statistical manual of mental disorders (4th ed.) Washing-
ton, DC: Author.
Andersen, B. L. (1992). Psychological interventions for
cancer patients to enhance the quality of life. Journal of
Consulting and Clinical Psychology, 60, 552±568.
 References
Andersen, B. L. (1996). Predicting, understanding, and
treating the sexual difficulties of gynecologic cancer
survivors. Cancer Control, 3, 27±33.
Andersen, B. L., Anderson, B., & deProsse, C. (1989a).
Controlled prospective longitudinal study of women
with cancer: I. Sexual functioning outcomes. Journal of
Consulting and Clinical Psychology, 57, 683±691.
Andersen, B. L., Anderson, B., & deProsse, C. (1989b).
Controlled prospective longitudinal study of women
with cancer: II. Psychological outcomes. Journal of
Consulting and Clinical Psychology, 57, 692±697.
Andersen, B. L., & Cacioppo, J. T. (1995). Delay in seeking
a cancer diagnosis: Delay stages and psychophysiological
comparison processes. British Journal of Social Psychol-
ogy, 34, 33±52.
Andersen, B. L., & Cyranowski, J. M. (1994). Women's
sexual self schema. Journal of Personality and Social
Psychology, 67, 1079±1100.
Andersen, B. L., & Elliott, M. L. (1994). Female cancer
survivors: Appreciating their sexual concerns. The
Canadian Journal of Human Sexuality, 3, 107±122.
Andersen, B. L., Karlsson, J. A., Anderson, B., & Tewfik,
H. H. (1984). Anxiety and cancer treatment: Response to
stressful radiotherapy. Health Psychology, 3, 535±551.
Andersen, B. L., Kiecolt-Glaser, J. K., & Glaser, R. (1994).
A biobehavioral model of cancer stress and disease
course. American Psychologist, 49, 389±404.
Andersen, B. L., & Lamb, M. A. (1995). Sexuality and
cancer. In A. I. Holleb, D. Fink, & G. P. Murphy (Eds.),
American Cancer Society textbook of clinical oncology
(2nd ed., pp. 699±713). Atlanta, GA: American Cancer
Society.
Andersen, B. L., & Tewfik, H. H. (1985). Psychological
reactions to radiation therapy: Reconsideration of the
adaptive aspects of anxiety. Journal of Personality and
Social Psychology, 48, 1024±1032.
Andersen, B. L., Turnquist, D., LaPolla, J., & Turner, D.
(1988). Sexual functioning after treatment of in situ
vulvar cancer: Preliminary report. Obstetrics & Gynecol-
ogy, 71, 15±19.
Andersen, B. L., Woods, X. A., and Copeland, L. J. (1997)
Sexual self schema and sexual morbidity among gyne-
cologic cancer survivors. Journal of Consulting and
Clinical Psychology, 65, 221±229.
Anderson, R. J., & Kirk, L. M. (1982). Methods of
improving patient compliance in chronic disease states.
Archives of Internal Medicine, 142, 1673±1675.
Andrykowski, M. A., Schmitt, F. A., Gregg, M. E., Brady,
M. J., Lamb, D. G., & Henslee-Downey, P. J. (1992).
Neuropsychologic impairment in adult bone marrow
transplant candidates. Cancer, 70, 2288±2297.
Andrykowski, M. A. (1993). The Morrow/Hickok article
reviewed: Behavioral treatment of chemotherapy-in-
duced nausea and vomiting. Oncology, 7, 93±94.
Andrykowski, M. A. (1994). Psychosocial factors in bone
marrow transplantation: A review and recommendations
for research. Bone Marrow Transplantation, 13, 357±375.
Ashburn, M. A., & Lipman, A. G. (1993). Management of
pain in the cancer patient. Anesthesia Analog, 76,
402±416.
Ashley, J. M. (1993). Dietary guidelines for cancer
prevention and control. Oncology, 7(suppl.) 27±31.
Baider, L., Cooper, C. L., & Kaplan De-Nour, A. (1996).
Cancer and the family. Chichester, UK: Wiley.
Baider, L., & Kaplan De-Nour, A. (1988). Adjustment to
cancer: Who is the patientÐthe husband or the wife?
Israel Journal of Medicine Sciences, 24, 631±636.
Baker, F., Curbow, B., & Wingard, J. R. (1991). Role
retention and quality of life of bone marrow transplant
survivors. Social Science and Medicine, 32, 697±704.
Bard, M., & Sutherland, A. M. (1952). Adaptation to
radical mastectomy. Cancer, 8, 656±671.
Bentler, P. M., & Newcomb, M. D. (1978). Longitudinal
233
study of marital success and failure. Journal of Consult-
ing and Clinical Psychology, 46, 1053±1070.
Bernstein, I. L. (1986). Etiology of anorexia in cancer.
Cancer, 58, 1881±1886.
Blanchard, C. G., Ruckdeschel, J. C., Labrecque, M. S.,
Frisch, S., Blanchard, E. B. (1987). The impact of a
designated cancer unit on house staff behaviors toward
patients. Cancer, 60, 2348±2354.
Bloom, J. R. (1987). Psychological response to mastect-
omy. A prospective comparison study. Cancer, 59,
189±196.
Brown, H. N., & Kelly, M. J. (1976). Stages of bone
marrow transplantation: A psychiatric perspective.
Psychosomatic Medicine, 38, 439±446.
Burish, T. G., & Jenkins, R. A. (1992). Effectiveness of
biofeedback and relaxation training in reducing the side
effects of cancer chemotherapy. Health Psychology, 11,
17±23.
Burish, T. G., Snyder, S. L., & Jenkins, R. A. (1991).
Preparing patients for cancer chemotherapy: Effect of
coping preparation and relaxation interventions. Journal
of Consulting and Clinical Psychology, 59, 518±525.
Byrne, J., Mulvihill, J. J., Connelly, R. R., Myers, M. H.,
Austin, D. A., Holmes, F. F., Holmes, G. E., Latourette,
H. G., Meigs, J. W., & Strong, L. C. (1988).
Reproductive problems and birth defects in survivors
of Wilm's tumor and their relatives. Medical and
Pediatric Oncology, 16, 233±240.
Byrne, J., Mulvihill, J. J., Myers, M. H., Abbott, S. C.,
Connelly, R. R., Hanson, M. R., Hassinger, D. D.,
Naughton, M. D., Austin, D. F., Gurgin, V. A., Holmes,
F. F., Homes, G. F., Latourette, H. B., Weyer, P. J.,
Meigs, J. W., Teta, M. J., Strong, L. C., & Cook, J. A.
(1985). Risk of infertility among survivors of childhood
and adolescent cancer. American Journal of Human
Genetics, 37, 24±48.
Cain, E. N., Kohorn, E. I., Quinlan, D. M., Latimer, K., &
Schwartz, P. E. (1986). Psychosocial benefits of a cancer
support group. Cancer, 57, 183±189.
Capone, M. A., Good, R. S., Westie, K. S., & Jacobson, A.
F. (1980). Psychosocial rehabilitation of gynecologic
oncology patients. Archives of Physical Medicine and
Rehabilitation, 61, 128±132.
Carey, M. P., & Burish, T. G. (1988). Etiology and
treatment of the psychological side effects associated
with cancer chemotherapy: A Critical review and
discussion Psychological Bulletin, 104, 307±325.
Carver, C. S., Pozo-Kaderman, C., Harris, S. D., Noriega,
V., Scheier, M. F., Robinson, D. S., Ketcham, A. S.,
Moffat Jr., F. L., & Clark, K. C. (1994). Optimism vs.
pessimism predicts the quality of women's adjustment to
early stage breast cancer. Cancer, 73, 1213±1220.
Cassileth, B. R., Lusk, E. J., Strouse, T. B., Miller, D. S.,
Brown, L. L., & Cross, P. A. (1985). A psychological
analysis of cancer patients and their next-of-kin. Cancer,
55, 72±76.
Cella, D. F., Orofiamma, B., Holland, J. C., Silberfarb, P.
M., Tross, S., Feldstein, M., Perry, M., Maurer, L. H.,
Comis, R., & Orav, E. J. (1987). The relationship of
psychological distress, extent of disease, and perfor-
mance status in patients with lung cancer. Cancer, 60,
1661±1667.
Cella, D. F., & Tross, S. (1986). Psychological adjustment
to survival from Hodgkin's disease. Journal of Consulting
and Clinical Psychology, 54, 616±622.
Christensen, D. N. (1983). Postmastectomy couple coun-
seling: An outcome study of a structured treatment
protocol. Journal of Sex & Marital Therapy, 9, 266±274.
Coates, R. J., Bransfield, D. D., Wesley, M., Hankey, B.,
Eley, J. W., Greenberg, R. S., Flanders, D., Hunter, C.
P., Edwards, B. K., Forman, M., Chen, V. W., Peynolds,
P., Boyd, P., Austin, D., Muss, H., & Blacklow, R. S.
(1992). Differences between black and white women with
234 Cancer
breast cancer in time from symptom recognition to
medical consultation. Journal of the National Cancer
Institute, 84, 938±950.
Coyle, N., Adelhardt, J., Foley, K. M., & Portenoy, R. K.
(1990). Character of terminal illness in the advanced
cancer patient: Pain and other symptoms during the last
four weeks of life. Journal of Pain and Symptom
Management, 5, 83±93.
Cunningham, M. P. (1997). Giving life to numbers. CAÐA
Cancer Journal for Clinicians, 47, 3±4.
Daut, R. L., Cleeland, C. S., & Flanery, R. C. (1983).
Development of the Wisconsin Brief Pain Questionnaire
to assess pain in cancer and other diseases. Pain, 17,
197±210.
deHaes, J. C., van Oostrom, M. A., & Welvaart, K. (1986).
The effect of radical and conserving surgery on quality of
life of early breast cancer patients, European Journal of
Surgical Oncology, 12, 337±342.
Derogatis, L. R., Morrow, G. R., Fetting, J., Penman, D.,
Piasetsky, S., Schmale, A. M., Henrichs, M., & Carnicke,
C. L. (1983). The prevalence of psychiatric disorders
among cancer patients. Journal of the American Medical
Association, 249, 751±757.
Devlen, J., Maguire, P., Phillips, P., Crowther, D., &
Chambers, H. (1987). Psychological problems associated
with diagnosis and treatment of lymphomas. I: Retro-
spective study and II: Prospective study. British Medical
Journal, 295, 953±957.
Dunkel-Schetter, C., Feinstein, L. G., Taylor, S. E., &
Falke, R. L. (1992). Patterns of coping with cancer.
Health Psychology, 11, 79±87.
Edgar, L., Rosberger, Z., & Nowlis, D. (1992). Coping with
cancer during the first year after diagnosis: Assessment
and intervention. Cancer, 69, 817±828.
Ell, K., Nishimoto, R., Mantell, J., & Hamovitch, M.
(1988). Longitudinal analysis of psychological adapta-
tion among family members of patients with cancer.
Journal of Psychosomatic Research, 32, 429±438.
Fawzy, F. I., Cousins, N., Fawzy, N. W., Kemeny, M. E.,
Elashoff, R., & Morton, D. (1990). A structured
psychiatric intervention for cancer patients: I. Changes
over time in methods of coping and affective disturbance.
Archives of General Psychiatry, 47, 720±725.
Fawzy, F. I., Fawzy, N. W., Hyun, C. S., Gutherie, D.,
Fahey, J. L., Morton, D. L., & Elashoff, R. (1993).
Maliganant melanoma: Effects of an early structured
psychiatric intervention, coping, and effective state on
recurrence and survival six years later. Archives of
General Psychiatry, 50, 681±689.
Fawzy, F. I., Kemeny, M. E., Fawzy, N. W., Elashoff, R.,
Morton, D., Cousins, N., & Fahey, J. L. (1990). A
structured psychiatric intervention for cancer patients:
II. Changes over time in immunological measures.
Archives of General Psychiatry, 47, 729±735.
Felton, B. J., Revenson, T. A., & Hinrichsen, G. A. (1984).
Stress and coping in the explanation of psychological
adjustment among chronically ill adults. Social Science
and Medicine, 18, 889±898.
Foley, K. M. (1985). The treatment of cancer pain. New
England Journal of Medicine, 313, 84±95.
Forester, B., Kornfeld, D. S., & Fleiss, J. (1985). Group
psychotherapy during radiotherapy: Effects on emo-
tional and physical distress. American Journal of
Psychiatry, 150, 1700±1706.
Futterman, A. D., Wellisch, D. K., Bond, G., & Carr, C. R.
(1991). The psychosocial levels system: A new rating
scale to identify and assess emotional difficulties during
bone marrow transplantation. Psychosomatics, 32,
177±186.
Garfinkel, L. (1994). Evaluating cancer statistics. CAÐA
Cancer Journal for Clinicians, 44, 5±6.
Gilbar, O., & Kaplan De-Nour, A. K. (1989) Adjustment
to illness and dropout of chemotherapy. Journal of
Psychosomatic Research, 33, 1±5.
Glanz, K., & Lerman, C. (1992). Psychosocial impact of
breast cancer: A critical review. Annals of Behavioral
Medicine, 14, 204±212.
Gottesman, D., & Lewis, M. S. (1982). Differences in crisis
reactions among cancer and surgery patients. Journal of
Consulting and Clinical Psychology, 50, 381±388.
Greene, P. G., Seime, R. J., & Smith, M. E. (1991).
Distraction and relaxation training in the treatment of
anticipatory vomiting: A single subject intervention.
Journal of Behavioral Therapy and Experimental Psy-
chiatry, 22, 285±290.
Greenwald, P., & Cullen, J. W. (1985). The new emphasis
in cancer control. Journal of the National Cancer
Institute, 74, 543±551.
Heber, D., Bagga, D., Ashley, J. M., & Elashloff, R. M.
(1993). Nutritional strategies for breast cancer preven-
tion. Oncology, 7, 43±46.
Helgeson, V. S., & Cohen, S. (1996). Social support and
adjustment to cancer: Reconciling descriptive, correla-
tional, and intervention. Health Psychology, 15, 135±148.
Herbert, T. B., & Cohen, S. (1993a). Depression and
immunity: A meta-analytic review. Psychological Bulle-
tin, 113, 472±486.
Herbert, T. B., & Cohen, S. (1993b). Stress and immunity
in humans: A meta-analytic review. Psychosomatic
Medicine, 55, 364±379.
Howson, J. Y. (1950). The procedures and results of the
Philadelphia committee for the study of pelvic cancer.
Wisconsin Medical Journal, 49, 215±219.
Hughson, A. V., Cooper, A. F., McArdle, C. S., & Smith,
D. C. (1987). Psychosocial effects of radiotherapy after
mastectomy. British Medical Journal, 294, 1515±1518.
Irvine, D., Brown, B., Crooks, D., Roberts, J., & Browne,
G. (1991). Psychosocial adjustment in women with breast
cancer. Cancer, 67, 1097±1117.
Irvine, D. M., Vincent, L., Bubela, N., Thompson, L., &
Graydon, J. (1991). A critical appraisal of the research
literature investigating fatigue in the individual with
cancer. Cancer Nursing, 14, 88±199.
Jacobson, P. B., & Schwartz, M. D. (1993). Food aversions
during cancer therapy: Incidence, etiology, and preven-
tion. Oncology, 7, 139±143.
Johnston, M., & Vogele, C. (1993). Benefits of psycholo-
gical preparation for surgery: A meta-analysis. Annals of
Behavioral Medicine, 15, 245±256.
Kaplan, H. S., & Owett, T. (1993). The female androgen
deficiency syndrome. Journal of Sex & Marital Therapy,
19, 3±24.
Keefe, F. J., Brantley, A., Manuel, G. M., Crisson, J. E.
(1985). Behavioral assessment of head and neck cancer
pain. Pain, 23, 327±336.
King, K. B., Nail, L. M., Kreamer, K., Strohl, R. A., &
Johnson, J. E. (1985). Patientsº descriptions of the
experience of receiving radiation therapy. Oncology
Nursing Forum, 12, 55±61.
Knox, L. S. (1991). Maintaining nutritional status in
persons with cancer. In Cancer nursing: Maintaining
nutritional status in persons with cancer (pp. 1±11).
Atlanta, GA: American Cancer Society.
Lansky, S. B., List, M. A., Herrman, C. A., Ets-Hokin, E.
G., Das Gupta, T. K., Wilbanks, G. D., & Hendrickson,
F. R. (1985). Absence of major depressive disorders in
female cancer patients. Journal of Clinical Oncology, 2,
1553±1560
Lebovits, A. H., Strain, J. J., Schleifer, S. J., Tanaka, J. S.,
Bhardwaj, S., & Messe, M. R. (1990). Patient noncom-
pliance with self-administration chemotherapy. Cancer,
65, 17±22.
Levin, S. H., Jones, L. D., & Sack, D. A. (1993).
Evaluation and treatment of depression, anxiety, and
insomnia in patients with cancer. Oncology, 7(suppl.),
119±125.
 References
Lewis, C., Linet, M. S., & Abeloff, M. D. (1983).
Compliance with cancer therapy by patients and physi-
cians. The American Journal of Medicine, 74, 673±678.
Linn, M. W., Linn, B. S., & Harris, R. (1982). Effects of
counseling for late stage cancer patients. Cancer, 49,
1048±1055.
Locke, B. Z., & Regier, D. A. (1985). Prevalence of selected
mental disorders. In C. A. Taube & S. A. Barrett (Eds.),
Mental Health United States (pp. 1±6). Rockville, MD:
National Institute of Mental Health.
Maguire, G. P., Lee, E. G., Bevington, D. J., Kuchemann,
C. S., Crabtree, R. J., & Cornell, C. E. (1978).
Psychiatric problems in the first year after mastectomy.
British Medical Journal, 1, 963±965.
Mahon, S. M., Cella, D. F., & Donovan, M. I. (1990).
Psychosocial adjustment to recurrent cancer. Oncology
Nursing Forum, 17, 47±52.
Maier, S. F., Watkins, L. R., & Fleshner, M. (1994).
Psychoneuroimmunology: The interface between beha-
vior, brain, and immunity. American Psychologist, 12,
1004±1017.
Manuel, G. M., Roth, S., Keefe, F. J., & Brantley, B. A.
(1987, Winter). Coping with cancer. Journal of Human
Stress, 13, 149±158.
Margolis, G., Goodman, R. L., & Rubin, A. (1990).
Psychological effects of breast-conserving cancer treat-
ment and mastectomy. Psychosomatics, 31, 33±39.
Marks, G., Richardson, J. L., Graham, J. W., & Levine, A.
(1986). Role of health locus of control beliefs and
expectations of treatment efficacy in adjustment to
cancer. Journal of Personality and Social Psychology,
51, 443±450.
Marshall, J. R., Gregorio, D. I., & Walsh, D. (1982). Sex
differences in illness behavior: Care seeking among
cancer patients. Journal of Health and Social Behavior,
23, 197±204.
Massie, M. J., & Holland, J. C. (1990). Depression and the
cancer patient. Journal of Clinical Psychiatry, 51, 12±19.
Massie, M. J., & Holland, J. C. (1992). The cancer patient
with pain: Psychiatric complications and their manage-
ment. Journal of Pain and Symptom Management, 7,
99±109.
Matthews, K. A., Siegel, J. M., Kuller, L. H., Thompson,
M., & Varat, M. (1983). Determinants of decision to
seek medical treatment by patients with acute myocar-
dial infarction symptoms. Journal of Personality and
Social Psychology, 44, 1144±1156.
Mizushima, Y., Kashii, T., Hoshino, K., Morikage, T.,
Takashima, A., Hirata, H., Kawasaki, A., Konisha, K.,
& Yano, S. (1990). A survey regarding the disclosure of
the diagnosis of cancer in Toyama prefecture, Japan.
Japanese Journal of Medicine, 29, 146±155.
Morris, T., Greer, H. S., & White, P. (1977). Psychological
and social adjustment to mastectomy: A two-year
follow-up study. Cancer, 40, 2381±2387.
Morrow, G. R. (1986). Effect of the cognitive hierarchy in
the systematic desensitization treatment of anticipatory
nausea in cancer patients: A component comparison
with relaxation only, counseling and no treatment.
Cognitive Therapy and Research, 10, 421-446.
Morrow, G. R., Asbury, R., Hammon, S., Dobkin, P.,
Caruso, L., Pandya, K., & Rosenthal, S. (1992).
Comparing the effectiveness of behavioral treatment
for chemotherapy-induced nausea and vomiting when
administered by oncologists, oncology nurses, and
clinical psychologists. Health Psychology, 11, 250±256.
Morrow, G. R., & Hickok, J. T. (1993). Behavioral
treatment of chemotherapy-induced nausea and vomit-
ing. Oncology, 7(Suppl.), 83±89.
Mosconi, P., Meyerowitz, B. E., Liberati, M. C., &
Liberati, A. (1991). Discolosure of breast cancer
diagnosis: Patient and physician reports. Annuals of
Oncology, 2, 273±280.
235
Munro, A. J., Biruls, R., Griffin, A. V., Thomas, H., &
Vallis, K. A. (1989). Distress associated with radio-
therapy for malignant disease: A quantitative analysis
based on patientsº perceptions. British Journal of
Cancer, 60, 370±374.
Nail, L. M., & King, K. B. (1997). Symptom distress
fatigue. Seminars in Oncology Nursing, 3, 257±262.
Nitschke, R., Humphrey, G. B., Sexauer, C. L., Catron, B.,
Wunder, S., & Jay, S. (1982). Therapeutic choices made
by patients with end-stage cancer. Journal of Pediatrics,
101, 471±476.
Northouse, L. L., & Peters-Golden, H. (1993). Cancer and
the family: Strategies to assist spouses. Seminars in
Oncology Nursing, 9, 74±82.
Pack, G. T., & Gallo, J. S. (1938). Culpability for delay in
treatment of cancer. American Journal of Cancer, 33,
443±462.
Parker, S. L., Tong, T., Bolden, S., & Wingo, P. P. (1997).
Cancer Statistics, 1997. CAÐA Cancer Journal for
Clinicians, 47, 5±27.
Patenaude, A. F. (1990). Psychological impact of bone
marrow transplantation: Current perspectives. The Yale
Journal of Biology and Medicine, 63, 515±519.
Pickard-Holley, S. (1991). Fatigue in cancer patients.
Cancer Nursing, 14, 13±19.
Rainey, L. C. (1985). Effects of preparatory patient
education for radiation oncology patients. Cancer, 56,
1056±1061.
Rathmell, A. J., Ash, D. V., Howes, M., & Nicholls, J.
(1991). Assessing quality of life in patients treated for
advanced head and neck cancer. Clinical Oncology, 3,
10±16.
Redd, W. H. (1993). The Morrow/Hickok article reviewed:
Behavioral treatment of chemotherapy-induced nausea
and vomiting. Oncology, 7, 94±95.
Redd, W. H., Andersen, G. V., & Minagawa, R. Y. (1982).
Hypnotic control of anticipatory emesis in patients
receiving cancer chemotherapy. Journal of Clinical and
Consulting Psychology, 50, 14±19.
Rhodes, V. A., Watson, P. M., & Hanson, B. M. (1988).
Patientsº descriptions of the influence of tiredness and
weakness on self-care abilities. Cancer Nursing, 11,
186±194.
Richardson, J. L., Marks, G., Johnson, C. A., Graham, J.
W., Chan, K. K., Selser, J. N., Kishbaugh, C., Barran-
day, Y., & Levine, A. M. (1987). Path model of
multidimensional compliance with cancer therapy.
Health Psychology, 6, 183±207.
Richardson, J. L., Marks, G., & Levine, A. (1988). The
influence of symptoms of disease and side effects of
treatment on compliance with cancer therapy. Journal of
Clinical Oncology, 6, 1746±1752.
Rimer, B. K. (1992). Understanding the acceptance of
mammography by women. Annals of Behavioral Medi-
cine, 14, 197±203.
Rothenberg, R. (1992). The new American medical dic-
tionary and health manual (6th ed.). New York: Penguin.
Rugo, H. (1993). Cancer. In L. Tierney, S. Mcphee, M.
Papadakis, & S. Schroeder (Eds.), CURRENT: Medical
diagnosis & treatment. Norwalk, CT: Appleton & Lange.
Sales, E., Schulz, R., & Biegel, D. (1992). Predictors of
strain in families of cancer patients: A review of the
literature. Journal of Psychosocial Oncology, 10, 1±26.
Sardell, A. N., & Trierweiler, S. J. (1993). Disclosing the
cancer diagnosis. Cancer, 72, 3355±3365.
Sell, L., Devlin, B., Bourke, S. J., Munro, N. C., Corris, P.
A., & Gibson, G. J. (1993). Communicating the
diagnosis of lung cancer. Respiratory Medicine, 87,
61±63.
Slavin, L. A., O'Malley, J. E., Koocher, G. P., & Foster, D.
J. (1982). Communication of the cancer diagnosis to
pediatric patients: Impact on long-term adjustment.
American Journal of Psychiatry, 139, 179±183.
236 Cancer
Smets, E. M., Garssen, B., Schuster-Uitterhoeve, A. L., &
deHaes, J. C. (1993). Fatigue in cancer patients. British
Journal of Cancer, 68, 220±224.
Sneed, N. V., Edlund, B., & Dias, J. K. (1992). Adjustment
of gynecological and breast cancer patients to the cancer
diagnosis: Comparisons with males and females having
other cancer sites. Health Care for Women International,
13, 11±22.
Speigel, D., & Bloom, J. R. (1983). Group therapy and
hypnosis reduce metastatic breast carcinoma pain.
Psychosomatic Medicine, 45, 333±339.
Speigel, D., Bloom, J. R., & Yalom, I. (1981). Group
support for patients with metastatic cancer: A rando-
mized outcome study. Archives of General Psychiatry, 38,
527±533.
Stewart, B. E., Meyerowitz, B. E., Jackson, L. E., Yarkin,
K. L., & Harvey, J. H. (1982, October). Psychological
stress associated with outpatient oncology nursing.
Cancer Nursing, 383±387.
Strang, P., & Qvarner, H. (1990). Cancer-related pain and
its influence on quality of life. Anticancer Research, 10,
109±112.
Syajala, K. L., Chapko, M. K., Vitaliano, P. P.,
Cummings, C., & Sullivan, K. M. (1993). Recovery after
allogeneic marrow transplantation: Prospective study of
predictors of long-term physical and psychosocial
functioning. Bone Marrow Transplantation, 11, 319±327.
Taylor, S. E. (1983). Adjustment to threatening events: A
theory of cognitive adaptation. American Psychologist,
38, 1161±1173.
Teeter, M. A., Holmes, G. E., Holmes, F. F., & Baker, A.
B. (1987). Decisions about marriage and family among
survivors of childhood cancer. Journal of Psychosocial
Oncology, 5, 59±68.
Telch, C. F., & Telch, M. J. (1986). Group coping skills
instruction and supportive group therapy for cancer
patients: A comparison of strategies. Journal of Consult-
ing and Clinical Psychology, 54, 802±808.
Teta, M. J., Del Po, M. C., Kasl, S. V., Meigs, J. W.,
Myers, M. H., & Mulvihill, J. J. (1986). Psychosocial
consequences of childhood and adolescent cancer survi-
val. Journal of Chronic Disease, 39, 751±759.
Thompson, L., Andersen, B. L., & DePetrillo, D. (1992).
The psychological processes of recovery from gynecolo-
gic cancer. In M. Coppleson (Ed.), Gynecologic oncology
(2nd ed.). Edinburgh, UK: Churchill Livingstone.
Vasterling, J., Jenkins, R. A., Tope, D. M., & Burish, T. G.
(1993). Cognitive distraction and relaxation training for
the control of side effects due to cancer chemotherapy.
Journal of Behavioral Medicine, 16, 65±80.
Vess, J. D., Moreland, J. R., & Schwebel, A. I. (1985). A
follow-up study of role functioning and the psychosocial
environment of families of cancer patients. Journal of
Psychosocial Oncology, 3, 1±14.
Vinokur, A. D., Threatt, B. A., Caplan, R. D., &
Zimmerman, B. L. (1989). Physical and psychosocial
functioning and adjustment to breast cancer: Long-term
follow-up of a screening population. Cancer, 63,
394±405.
Wallace, L. M., Priestman, S. G., Dunn, J. A., &
Priestman, T. J. (1993). The quality of life of early
breast cancer patients treated by two different radio-
therapy regimens. Clinical Oncology, 5, 228±233.
Wardle, J., & Pope, R. (1992). The psychological costs of
screening for cancer. Journal of Psychosomatic Research,
36, 609±624.
Waters, W. E., Nichols, S., Wheeler, M. J., Fraser, J., &
Hayes, A. J. (1983). Evaluation of a health education
campaign to reduce the delay in women presenting with
breast symptoms. Community Medicine, 5, 104±108.
Weisman, A. D., & Worden, J. W. (1976). The existential
plight in cancer: Significance of the first 100 days.
International Journal of Psychiatry in Medicine, 7, 1±15.
Westbrook, M. T., & Viney, L. L. (1982). Psychological
reactions to the onset of chronic illness. Social Science
and Medicine, 16, 899±905.
Wilkinson, S. (1991). Factors which influence how nurses
communicate with cancer patients. Journal of Advanced
Nursing, 16, 677±688.
Winer, E. P., & Sutton, L. M. (1994). Quality of life after
bone marrow transplantation. Oncology, 8, 19±27.
Wingard, J. R., Curbow, B., Baker, F., & Piantadosi, S.
(1991). Health, functional status, and employment of
adult survivors of bone marrow transplantation. Annals
of Internal Medicine, 114, 113±118.
Wolf, D. M., & Jordan, V. C. (1992). Gynecologic
complications associated with long-term adjuvant ta-
moxifen therapy for breast cancer. Gynecologic Oncol-
ogy, 45, 118±128.
Woodard, L. J., & Pamies, R. J. (1992). The disclosure of
the diagnosis of cancer. Primary Care, 19, 657±663.
Wortman, C. B., & Dunkel-Schetter, C. (1979). Interper-
sonal relationships and cancer: A theoretical analysis.
Journal of Social Issues, 35, 120±155.
Wynder, E. L., & Cohen, L. A. (1993). Nutritional
opportunities and limitations in cancer prevention.
Oncology, 7(Suppl.) 13±16.