Center on Stress and Health


Collie, K., M. A. Kreshka, et al. (2007). "Videoconferencing for delivery of breast cancer support groups to women living in rural communities: a pilot study." Psychooncology 16(8): 778-82.
Women with breast cancer in rural areas are likely to exhaust their usual sources of psychosocial support while still facing challenges posed by breast cancer, but are unlikely to have access to professionally led support groups. In this community-based project, we assessed the feasibility and acceptability of providing support groups to women with breast cancer in a large rural area using videoconferencing and a workbook journal, and we assessed the intervention's potential to reduce distress and increase emotional expression and self-efficacy for coping with cancer. Twenty-seven women in the Intermountain Region of northeastern California participated in eight-session support groups led by an oncology social worker by going to nearby videoconferencing sites. Feasibility and acceptability were demonstrated. Older as well as younger women were comfortable using videoconferencing and said the groups were valuable because they promoted information sharing and emotional bonds with other women with breast cancer. They emphasized the importance of a professional facilitator and identified advantages of using videoconferencing for support groups. Pretest and posttest comparisons showed significant decreases in depression and posttraumatic stress disorder symptoms. The results suggest that the intervention has the potential to provide a valuable service that is not readily available in rural communities. Copyright (c) 2007 John Wiley & Sons, Ltd.

Giese-Davis, J., F. H. Wilhelm, et al. (2006). "Depression and stress reactivity in metastatic breast cancer." Psychosom Med 68(5): 675-83.
OBJECTIVE: Cancer-related distress due to the psychological and physical challenges of metastatic breast cancer (MBC) may result in symptoms of depression, which negatively affects quality and may influence quantity of life. This study investigated how depression affects MBC stress reactivity, including autonomic (ANS) and hypothalamic-pituitary-adrenal (HPA) axis function. METHOD: Forty-five nondepressed and 45 depressed patients with MBC underwent a modified Trier Social Stress Test (TSST) while affect, cardiovascular, respiratory, and cortisol responses were measured. RESULTS: At study entry, depressed compared with nondepressed patients had significantly lower log cortisol waking rise levels (p = .005) but no other HPA differences. Positive affect (p = .025) and high-frequency heart-rate variability (lnHF) (p = .002) were significantly lower at TSST baseline in depressed patients. In response to the TSST, depressed patients reported significantly lower positive (p = .050) and greater negative affect (p = .037) and had significantly reduced lnHF (p = .031). In secondary analyses, at TSST baseline both low-frequency (lnLF) (p = .002) and very-low-frequency (lnVLF) (p = .0001) heart rate variability were significantly lower in the depressed group. In secondary analyses during the TSST, those who were depressed had significantly lower lnVLF (p = .008) and did not increase aortic impedance reactivity as much as did the nondepressed during the stressor (p = .005). CONCLUSION: Depression in patients with MBC was associated with alterations in autonomic regulation, particularly reductions in respiratory sinus arrhythmia, a measure of cardiac vagal control, at baseline and during the TSST. In addition, depression was associated with blunted HPA response to awakening. Both MBC groups had relative cortisol hyporesponsiveness to acute stress.

Levy, M. H., A. Back, et al. (2006). "Palliative care. Clinical practice guidelines in oncology." J Natl Compr Canc Netw 4(8): 776-818.

Owen, J. E., J. Giese-Davis, et al. (2006). "Self-report and linguistic indicators of emotional expression in narratives as predictors of adjustment to cancer." J Behav Med 29(4): 335-45.
Emotional expression and cognitive efforts to adapt to cancer have been linked to better psychological adjustment. However, little is known about the relationship between linguistic indicators of emotional and cognitive coping efforts and corresponding self-report measures of related constructs. In this study, we sought to evaluate the interrelationships between self-reports of emotional suppression and linguistic indicators of emotional and cognitive coping efforts in those living with cancer. Seventy-one individuals attending a community cancer support group completed measures of emotional suppression and mood disturbance and provided a written narrative describing their cancer experience. Self-reports of emotional suppression were associated with more rather than less distress. Although linguistic indicators of both emotional expression and cognitive processing were generally uncorrelated with self-report measures of emotional suppression and mood disturbance, a significant interaction was observed between emotional suppression and use of cognitive words on mood disturbance. Among those using higher levels of emotional suppression, increasing use of cognitive words was associated with greater levels of mood disturbance. These findings have implications for a) the therapeutic use of emotion in psychosocial interventions and b) the use of computer-assisted technologies to conduct content analysis.

Palesh, O. G., T. Shaffer, et al. (2006). "Emotional self-efficacy, stressful life events, and satisfaction with social support in relation to mood disturbance among women living with breast cancer in rural communities." Breast J 12(2): 123-9.
This study evaluated the relationships of emotional self-efficacy, stressful life events, and social support with mood disturbance among women diagnosed with breast cancer who live in rural communities. Eighty-two women completed measures of demographic characteristics, medical status, and psychosocial variables. Using multiple regression analysis, we found that greater mood disturbance was related to having less emotional self-efficacy (p < 0.001) and to having experienced more stressful life events (p = 0.02), while satisfaction with social support was not significantly related to mood disturbance (adjusted R2 = 0.39). Women living with breast cancer in rural communities who have experienced multiple stressful life events may have an increased risk for mood disturbance, whereas having greater emotional self-efficacy may provide resilience against mood disturbance.

Reuter, K., C. C. Classen, et al. (2006). "Association of coping style, pain, age and depression with fatigue in women with primary breast cancer." Psychooncology 15(9): 772-9.
The purpose of this study was to explore the relative contributions of coping, depression, pain and age, in the experience of cancer related fatigue. A total of 353 women treated for primary breast cancer were assessed within one year of diagnosis using the Profile of Mood States, the Hospital Anxiety and Depression Scale and the mini-Mental Adjustment to Cancer Scale. Fatigue was positively associated with depression and pain, but inversely related to age. In contrast to our expectations, fighting spirit was not associated with less fatigue. A relationship between coping style and cancer-related fatigue was found exclusively for 'positive reappraisal', a combination of fighting spirit and fatalism. Detectable only in multivariate analysis together with depression, the results suggest a weak association between coping and fatigue. The relationship between cancer related fatigue, age and coping styles requires further exploration within longitudinal studies.

Sephton, S. E., H. C. Kraemer, et al. (2006). "Improving methods of assessing natural killer cell cytotoxicity." Int J Methods Psychiatr Res 15(1): 12-21.
Natural killer (NK) cells are a class of lymphocytes important in immune resistance to viral and other serious diseases. The cytotoxic function, or 'killing activity' of NK cells has become important in studies of the effects of stress and other psychosocial factors on physical health. Unfortunately, research on NK cell function has been plagued by discrepancies in the methods of interpreting NK cytotoxicity data. We briefly review some of the variations in measuring NK cell activity and present a new model for interpreting these results, introducing maximal target cell lysis (A) and the slope of the cytolytic curve (k) as parameters that attempt to make full use of the information and the statistical power in NK cell cytotoxicity data. Examples of these interpretation methods are presented using NK cytotoxicity data from a group of metastatic breast cancer patients. This approach will be useful in applications of NK cell measurement in psychoneuroimmunology research.

Spiegel, D., J. Giese-Davis, et al. (2006). "Stress sensitivity in metastatic breast cancer: analysis of hypothalamic-pituitary-adrenal axis function." Psychoneuroendocrinology 31(10): 1231-44.
The normal diurnal cortisol cycle has a peak in the morning, decreasing rapidly over the day, with low levels during the night, then rising rapidly again to the morning peak. A pattern of flatter daytime slopes has been associated with more rapid cancer progression in both animals and humans. We studied the relationship between the daytime slopes and other daytime cortisol responses to both pharmacological and psychosocial challenges of hypothalamic-pituitary-adrenal (HPA) axis function as well as DHEA in a sample of 99 women with metastatic breast cancer, in hopes of elucidating the dysregulatory process. We found that the different components of HPA regulation: the daytime cortisol slope, the rise in cortisol from waking to 30 min later, and cortisol response to various challenges, including dexamethasone (DEX) suppression, corticotrophin releasing factor (CRF) activation, and the Trier Social Stress Task, were at best modestly associated. Escape from suppression stimulated by 1mg of DEX administered the night before was moderately but significantly associated with flatter daytime cortisol slopes (r=0.28 to .30 at different times of the post DEX administration day, all p<.01). Daytime cortisol slopes were also moderately but significant associated with the rise in cortisol from waking to 30 min after awakening (r=.29, p=.004, N=96), but not with waking cortisol level (r=-0.13, p=.19). However, we could not detect any association between daytime cortisol slope and activation of cortisol secretion by either CRF infusion or the Trier Social Stress Task. The CRF activation test (following 1.5mg of DEX to assure that the effect was due to exogenous CRF) produced ACTH levels that were correlated (r=0.66, p<.0001, N=74) with serum cortisol levels, indicating adrenal responsiveness to ACTH stimulation. Daytime cortisol slopes were significantly correlated with the slope of DHEA (r=.21, p=.04, N=95). Our general findings suggest that flatter daytime cortisol slopes among metastatic breast cancer patients may be related to disrupted feedback inhibition rather than hypersensitivity in response to stimulation.

Spiegel, D. A., P. H. Helseth, et al. (2006). "Atypical scoliosis in a 14-year-old girl." Clin Orthop Relat Res 447: 270-6.

Turner-Cobb, J. M., L. E. Bloor, et al. (2006). "Disengagement and social support moderate distress among women with a family history of breast cancer." Breast J 12(1): 7-15.
Using a cross-sectional, exploratory design, this pilot study analyzed the relationships between familial history of breast cancer and psychological distress in order to evaluate who is more distressed and to assess the possible need for intervention. Coping style, social support, and family relations were investigated as potential moderators of these relationships. Participants were 45 women with a familial history of breast cancer recruited from the Family Registry for Breast Cancer (FRBC) at the Northern California Cancer Center (NCCC). Contrary to previous reports of similar cohorts, the overall level of psychological distress in this cohort was comparable to normative samples. The number of relatives with breast cancer was related to distress as measured by the State-Trait Anxiety Inventory (STAI) scale, but there was no significant differentiation in distress associated with the number of first-degree as compared to second- and third-degree relatives with breast cancer. Having more relatives that had died from breast cancer was associated with greater distress on a number of measures. The number of first-degree relative deaths, including maternal death, was also associated with distress. Positive and network support, disengagement coping responses, and family cohesion were each significant moderators of the impact of family history on distress. This association between distress and disengagement is similar to that found in metastatic breast cancer patients themselves, and the findings suggest a subgroup that merits and might respond to more intensive intervention to provide support and facilitate emotional expression.

Wong, M., E. Looney, et al. (2006). "A preliminary study of peritraumatic dissociation, social support, and coping in relation to posttraumatic stress symptoms for a parent's cancer." Psychooncology 15(12): 1093-8.
This study examined predictors of posttraumatic stress disorder (PTSD) symptoms in adults who, as children, had a parent diagnosed with cancer. Possible predictors of adulthood PTSD examined were peritraumatic dissociation, satisfaction with social support, coping through denial, behavioral disengagement and self-distraction, and whether or not the parent died. Thirty research participants (20 women and 10 men, ages 18-38) were recruited who were 8-17-years old at the time of a parent's cancer diagnosis. Each participant completed measures of their current PTSD symptoms in response to their parent's cancer, peritraumatic dissociative experiences, demographic characteristics, and satisfaction with social support and use of coping strategies at the time of their parent's cancer diagnosis. Seventeen percent met screening criteria for likely PTSD. As hypothesized, PTSD symptoms were strongly and positively correlated with peritraumatic dissociation. Furthermore, PTSD symptoms were greater among females and were related to greater use of denial and behavioral disengagement and to less satisfaction with social support. These results suggest that health care providers need to recognize symptoms of peritraumatic dissociation in the children of parents who are diagnosed with cancer so that steps can be taken to minimize the children's development of PTSD that may extend into their adult lives.

Antoni, M. H., S. K. Lutgendorf, et al. (2006). "The influence of bio-behavioural factors on tumour biology: pathways and mechanisms." Nat Rev Cancer 6(3): 240-8.
Epidemiological studies indicate that stress, chronic depression and lack of social support might serve as risk factors for cancer development and progression. Recent cellular and molecular studies have identified biological processes that could potentially mediate such effects. This review integrates clinical, cellular and molecular studies to provide a mechanistic understanding of the interface between biological and behavioural influences in cancer, and identifies novel behavioural or pharmacological interventions that might help improve cancer outcomes.

Chan, C. L., R. T. Ho, et al. (2006). "A randomized controlled trial of psychosocial interventions using the psychophysiological framework for Chinese breast cancer patients." J Psychosoc Oncol 24(1): 3-26.
This study aimed to investigate the psychophysiological outcomes of different psychosocial interventions for breast cancer patients. Participants were randomly assigned into 3 intervention groups, namely, Body-Mind-Spirit (BMS), Supportive-Expressive (SE), and Social Support Self-Help (SS) groups; a no-intervention group was used as control. Salivary cortisol was used as the physiological stress marker. Distress level, mental adjustment, emotional control, and social support were measured. Data were collected at baseline, 4 month, and 8 month. Preliminary results indicated that BMS intervention produced the greatest and the most sustained effects. It enhanced positive social support, reduced psychological distress, emotional control, and negative mental adjustment. Total salivary cortisol was lowered after 8 months. Most participants in SE groups indicated the treatment helpful, but changes in psychophysiological outcomes were not statistically significant. Participants in SS groups seemed less likely to benefit from the intervention. The no intervention control group indicated a reduction in social support. These outcomes suggest that active professional intervention is more likely to yield therapeutic effects. In particular, psychosocial intervention attending to the spiritual dimension contributes to positive outcomes.

Choumanova, I., S. Wanat, et al. (2006). "Religion and spirituality in coping with breast cancer: perspectives of Chilean women." Breast J 12(4): 349-52.
This study examined the roles of religion and spirituality in relation to coping with breast cancer in Chilean women. Specifically, the purpose of the study was to examine how these patients used religion and spirituality to cope with their illness; how their illness changed the roles of religion and spirituality in their lives; and their views regarding whether, and if so how, spiritual faith can help patients recuperate from breast cancer. Twenty-seven women with breast cancer who were patients at a clinic in Santiago, Chile were recruited to participate in one-on-one interviews. The transcribed interviews were analyzed using the "constant comparative method" to seek patterns and organize the content into specific themes. Women viewed religion and spirituality as primary resources for themselves and others to use in coping with breast cancer. Women's use of religion and spirituality was manifested in praying, in their perceived dependence on God to intercede and guide them through their illness, and in obtaining social support from other persons in their faith community. Half (13/26) of the women reported that their cancer prompted an increased emphasis on religion and spirituality in their lives by deepening their faith in God. Almost all (26/27) participants endorsed the belief that spiritual faith can help cancer patients to recuperate. These findings suggest that health care providers working should be aware of the culturally dependent roles that religion and spirituality play in women's coping with breast cancer.

Giese-Davis, J., C. Bliss-Isberg, et al. (2006). "The effect of peer counseling on quality of life following diagnosis of breast cancer: an observational study." Psychooncology 15(11): 1014-22.
Women with breast cancer express the greatest need for counseling at the time of diagnosis and report that the intervention they want is to be able to speak with someone who has the same cancer, but has lived through the crisis of treatment and is leading a 'normal' life. We conducted an observational study of a 6-month peer-counseling intervention testing outcomes for both newly diagnosed women (Sojourners) and peer counselors (Navigators) as a first step toward the goal of validating a peer navigator program. Significant improvement in the Sojourners was observed in trauma symptoms, emotional well-being, cancer self-efficacy, and desire for information on breast cancer resources. Navigators maintained baseline levels of the outcome variables, but increased in dissatisfaction with their interactions with their medical team and increased emotional suppression. Our findings indicate that peer navigation may halt a decline in quality of life that is commonly found in the first year following breast cancer diagnosis. In addition, Navigators were not adversely affected by their experience; however, careful training and supervision of Navigators is crucial to overall success. Randomized clinical trials are needed to demonstrate the efficacy of peer navigator programs.

Giese-Davis, J., S. DiMiceli, et al. (2006). "Emotional expression and diurnal cortisol slope in women with metastatic breast cancer in supportive-expressive group therapy: a preliminary study." Biol Psychol 73(2): 190-8.
We examined coded emotional expression during an initial therapy session and its association with a known physiological risk factor for early death, aberrant diurnal cortisol slope, in women with metastatic breast cancer. Out of 64 women with metastatic breast cancer randomized to a multi-site clinical intervention trial of supportive-expressive group therapy (SET), a subsample of 29 met eligibility criteria for this study. We tested whether longer mean durations of primary negative affect (fear, sadness, and anger) expression were associated with steeper diurnal cortisol slopes after adjusting for speaking time, repressive-defensiveness, anxiety, and the interaction between repressive-defensiveness and anxiety. We found that steeper cortisol slopes were related to lower repressive-defensiveness and greater primary negative affect expression in line with a priori hypotheses. Additionally we explored whether coded positive affect, defensive/hostile affect, constrained anger, and the interaction between primary negative affect and repressive-defensiveness explained additional variance in diurnal cortisol patterns.

Han, W. T., K. Collie, et al. (2005). "Breast cancer and problems with medical interactions: relationships with traumatic stress, emotional self-efficacy, and social support." Psychooncology 14(4): 318-30.
This investigation examined relationships between breast cancer patients' psychosocial characteristics (impact of the illness, traumatic stress symptoms, emotional self-efficacy, and social support) and problems they perceived in their medical interactions and their satisfaction with their physicians. Participants were 352 women enrolled in a multicenter trial of the effects of group therapy for women with recently diagnosed primary breast cancer. The findings reported here are from a cross-sectional analysis of baseline data gathered prior to randomization. Problems interacting with physicians and nurses were associated with greater levels of cancer-related traumatic stress (p < 0.01), less emotional self-efficacy for cancer (p < 0.05), less satisfaction with informational support from family, friends, and spouse, and a tendency to perceive those sources of support as more aversive (p < 0.05). Women who were less satisfied with emotional support from their family, friends and spouse were less likely to feel satisfied with their physicians (p < 0.05). These patient characteristics identify women with primary breast cancer who are likely to experience difficulty in their interactions with nurses and physicians and to be less satisfied with their physicians.

Saul, A. N., T. M. Oberyszyn, et al. (2005). "Chronic stress and susceptibility to skin cancer." J Natl Cancer Inst 97(23): 1760-7.
BACKGROUND: Studies have shown that chronic stress or UV radiation independently suppress immunity. Given their increasing prevalence, it is important to understand whether and how chronic stress and UV radiation may act together to increase susceptibility to disease. Therefore, we investigated potential mediators of a stress-induced increase in emergence and progression of UV-induced squamous cell carcinoma. METHODS: SKH1 mice susceptible to UV-induced tumors were unexposed (naive, n = 4) or exposed (n = 16) to 2240 J/m2 of UVB radiation three times a week for 10 weeks. Half of the UVB-exposed mice were left nonstressed (i.e., they remained in their home cages) and the other half were chronically stressed (i.e., restrained during weeks 4-6). UV-induced tumors were measured weekly from week 11 through week 34, blood was collected at week 34, and tissues were collected at week 35. mRNA expression of interleukin (IL)-12p40, interferon (IFN)-gamma, IL-4, IL-10, CD3epsilon, and CCL27/CTACK, the skin T cell-homing chemokine, in dorsal skin was quantified using real-time polymerase chain reaction. CD4+, CD8+, and CD25+ leukocytes were counted using immunohistochemistry and flow cytometry. All statistical tests were two-sided. RESULTS: Stressed mice had a shorter median time to first tumor (15 versus 16.5 weeks, difference = 1.5 weeks, 95% confidence interval [CI] = -3.0 to 3.3 weeks; P = .03) and reached 50% incidence earlier than controls (15 weeks versus 21 weeks). Stressed mice also had lower IFN-gamma ( mean = 0.03 versus mean = 0.07, difference = 0.04, 95% CI = 0.004 to 0.073; P = .02), CCL27/CTACK (mean = 101 versus mean = 142, difference = 41, 95% CI = 8.1 to 74.4; P = .03), and CD3epsilon (mean = 0.18 versus mean = 0.36, difference = 0.18, 95% CI = 0.06 to 0.30; P = .007) gene expression and lower numbers of infiltrating CD4+ cells (mean = 9.40 versus mean = 13.7, difference = 4.3, 95% CI = 2.36 to 6.32; P = .008) than nonstressed mice. In addition, stressed mice had more regulatory/suppressor CD25+ cells infiltrating tumors and more CD4+ CD25+ cells in circulation (mean = 0.36 versus mean = 0.17, difference = 0.19, 95% CI = 0.005 to 0.38; P = .03) than nonstressed mice. CONCLUSIONS: Chronic stress increased susceptibility to UV-induced squamous cell carcinoma in this mouse model by suppressing type 1 cytokines and protective T cells and increasing regulatory/suppressor T cell numbers.

Abercrombie, H. C., J. Giese-Davis, et al. (2004). "Flattened cortisol rhythms in metastatic breast cancer patients." Psychoneuroendocrinology 29(8): 1082-92.
Allostatic load, the physiological accumulation of the effects of chronic stressors, has been associated with multiple adverse health outcomes. Flattened diurnal cortisol rhythmicity is one of the prototypes of allostatic load, and has been shown to predict shorter survival among women with metastatic breast cancer. The current study compared diurnal cortisol slope in 17 breast cancer patients and 31 controls, and tested associations with variables previously found to be related to cortisol regulation, i.e, abdominal adiposity, perceived stress, social support, and explicit memory. Women with metastatic breast cancer had significantly flatter diurnal cortisol rhythms than did healthy controls. Patients with greater disease severity showed higher mean cortisol levels, smaller waist circumference, and a tendency toward flatter diurnal cortisol rhythms. There were no relations between cortisol slope and psychological or cognitive functioning among patients. In contrast, controls with flatter rhythms showed the expected allostatic load profile of larger waist circumference, poorer performance on explicit memory tasks, lower perceived social support, and a tendency toward higher perceived stress. These findings suggest that the cortisol diurnal slope may have important but different correlates in healthy women versus those with breast cancer.

Giese-Davis, J., S. E. Sephton, et al. (2004). "Repression and high anxiety are associated with aberrant diurnal cortisol rhythms in women with metastatic breast cancer." Health Psychol 23(6): 645-50.
Previous research has provided evidence of autonomic, endocrine, and immunological dysregulation in repressers and a possible association with cancer incidence and progression. Recently published data from the authors' laboratory demonstrated that flatter diurnal cortisol slopes were a risk factor for early mortality in women with metastatic breast cancer. In the current analysis of this same sample (N=91), the authors tested differences at baseline between groups scored using the Weinberger Adjustment Inventory on diurnal cortisol slope and mean cortisol levels. When compared with self-assured and nonextreme groups, the represser and high-anxious groups had a significantly flatter diurnal slope. Diurnal slope was similar for repressers and high-anxious groups. Groups did not differ on mean cortisol levels, nor did they differ on intercept (morning) values.

Blake-Mortimer, J. S., S. E. Sephton, et al. (2004). "Cytotoxic T lymphocyte count and survival time in women with metastatic breast cancer." Breast J 10(3): 195-9.
While prognostic factors in early stage breast cancer are well documented, few studies have examined predictors of the rate of metastatic progression. The purpose of this study was to examine cytotoxic T-cell lymphocyte (CTL) count as a marker of disease status in women with metastatic breast cancer. This study examined CTL subset counts as predictors of subsequent survival in 113 women with metastatic or recurrent breast cancer. Samples were measured by flow cytometry using monoclonal antibodies for cell surface antigens for percentages and absolute numbers of CTLs (CD3/CD8), total lymphocytes, T cells (CD3), helper T cells (CD3/CD4), and total white blood cell (TWC) count. Higher CTL counts emerged as a significant predictor of longer survival up to 7 years later (Wald = 7.40, p = 0.007; Cox regression model). The relationship of higher CTL count with enhanced survival was independent of the effects of medical treatment. CTLs were significantly associated with TWC count (r = 0.42, p < 0.001). However, TWC count was not associated with subsequent survival time. Higher CTL count was associated with Karnofsky performance status (r = 0.27, p = 0.004). However, after adjustment for the Karnofsky score, the CTL count/survival relationship remained significant (Wald = 4.33, p = 0.038). In conclusion, there is a robust relationship between CTL count and survival that is independent of the effects of medical treatments, TWC count, and Karnofsky performance status. Moreover, a reduced CTL count may be a mediator or marker of more rapid disease progression in metastatic breast cancer.

Rosenbaum, E., H. Gautier, et al. (2004). "Cancer supportive care, improving the quality of life for cancer patients. A program evaluation report." Support Care Cancer 12(5): 293-301.
GOALS OF WORK: As medical care for cancer has become more specialized in diagnosis, treatment has become more technical and fragmented. In order to help cancer patients and their families, we developed a coordinated program called the Stanford Cancer Supportive Care Program (SCSCP) at the Center for Integrative Medicine at Stanford Hospital and Clinics. The Stanford Cancer Supportive Care Program was initiated in 1999 to provide support for cancer patients, addressing the need for improved physical and emotional well-being and quality of life. This paper is a program evaluation report. PATIENTS AND METHODS: The number of patient visits grew from 421 in 1999 to 6319 in 2002. This paper describes the utilization of the SCSCP program as assessed by 398 patient visit evaluations during a 9-week period, January 2002 to March 2002. During this time we collected attendance records with demographic data and anonymous questionnaires evaluating each program. Patients were asked to evaluate how the program helped them regarding increase of energy, reduction in stress, restful sleep, pain reduction, sense of hopefulness, and empowerment. MAIN RESULTS: Over 90% of the patients using the SCSCP felt there was benefit to the program. Programs were chosen based on a needs assessment by oncologists, nurse managers, social workers, and patients. Massage, yoga, and qigong classes had the highest number of participants. Qualitative data showed benefit for each program offered. CONCLUSIONS: This evaluation of a free cancer supportive care program initiated in a hospital outpatient setting provides initial evidence of patient satisfaction and improvement in quality of life.

Turner-Cobb, J. M., C. Koopman, et al. (2004). "The interaction of social network size and stressful life events predict delayed-type hypersensitivity among women with metastatic breast cancer." Int J Psychophysiol 54(3): 241-9.
This study examined relationships between social support, stressful life events and antigen-specific cell-mediated immunity. Participants were 72 women with documented metastatic breast carcinoma, who completed self-report measures of social support and life stress. Immune response was assessed using the delayed type hypersensitivity (DTH) skin test. Number of positive antigens was significantly related to the interaction of social network size and stressful life events (p<0.05). Number of positive antigens was greater for women who had experienced a high frequency of stressful life events but who reported a larger network of support. However, social network size was inversely related to DTH response among women who had experienced fewer stressful life events. Average induration size was not significantly related to the quality of social support, life stress per se, or their interactions. The relationship between social network size and immune response in women with metastatic breast cancer depends on prior stressful life experience.

Angell, K. L., M. A. Kreshka, et al. (2003). "Psychosocial intervention for rural women with breast cancer: The Sierra-Stanford Partnership." J Gen Intern Med 18(7): 499-507.
OBJECTIVE: This study was initiated by breast cancer survivors living in a rural community in California. They formed a partnership with academic researchers to develop and evaluate a low-cost, community-based Workbook-Journal (WBJ) for improving psychosocial functioning in geographically and economically isolated women with primary breast cancer. DESIGN: A randomized controlled trial was used to compare the WBJ intervention plus educational materials to educational materials alone (usual care). SETTING: One rural cancer center and several private medical, surgical, and radiation oncology practices in 7 rural counties in the Sierra Nevada Foothills of California. PARTICIPANTS: One hundred women with primary breast cancer who were either within 3 months of diagnosis or within 3 months of completing treatment. INTERVENTION: A community-initiated, theoretically-based Workbook-Journal, designed by rural breast cancer survivors and providers as a support group alternative. It included compelling personal stories, local rural resources, coping strategies, and messages of hope. RESULTS: Community recruiters enrolled 83% of the women referred to the study. Retention at 3-month follow-up was 98%. There were no main effects for the WBJ. However, 3 significant interactions suggested that women who were treated in rural practices reported decreased fighting spirit and increased emotional venting and posttraumatic stress disorder symptoms if they did not receive the WBJ. Among women who receive the WBJ, 74% felt emotionally supported. CONCLUSIONS: This community-based Workbook-Journal may be an effective psychosocial intervention for rural, isolated, and low-income women with breast cancer. Community involvement was essential to the success of this project.

Cordova, M. J., J. Giese-Davis, et al. (2003). "Mood disturbance in community cancer support groups. The role of emotional suppression and fighting spirit." J Psychosom Res 55(5): 461-7.
OBJECTIVE: In this cross-sectional study, we tested whether the coping styles of emotional suppression and fighting spirit were associated with mood disturbance in cancer patients participating in professionally led community-based support groups even when demographic, medical, and group support variables were taken into account. METHODS: A heterogeneous sample of 121 cancer patients (71% female, 29% male) completed the Courtauld Emotional Control Scale (CECS), the Mini-Mental Adjustment to Cancer Scale (Mini-MAC), a measure of perceived group support, and the Profile of Mood States (POMS). RESULTS: Consistent with hypotheses, lower emotional suppression and greater adoption of a fighting spirit, in addition to older age and higher income, were associated with lower mood disturbance. Gender, time since diagnosis, presence of metastatic disease, time in the support group, perceived group support, cognitive avoidance, and fatalism were unrelated to mood disturbance. CONCLUSION: Expression of negative affect and an attitude of realistic optimism may enhance adjustment and reduce distress for cancer patients in support groups.

Grumann, M. M. and D. Spiegel (2003). "Living in the face of death: interviews with 12 terminally ill women on home hospice care." Palliat Support Care 1(1): 23-32.
OBJECTIVE: To determine how home hospice patients deal with their impending death and whether there is a need for greater involvement of mental health professionals in the care of patients dying at home. METHOD: In a pilot study, 12 female home hospice patients with advanced cancer and a median survival time of 42 days were assessed using structured interviews and brief questionnaires. Topics of inquiry included facing death, fear of death, pain, fatigue, depression, and anxiety. Three key themes were extracted from the information reported by the women: (1) confronting the issue of death, (2) fear of dying and death and its correlates, and (3) spirituality/religious faith and its role in mitigating fear of death. RESULTS: First, all subjects reported thinking about their approaching death. For half of them, this thought was bothersome and these women were frequently troubled by unresolved issues and higher anxiety, pain, and fatigue. The majority of the subjects expressed a desire to actively discuss their impending death. Second, more than half of the patients reported being afraid of death and high death anxiety was associated with fear of dying in pain, high peak or usual pain, unresolved issues, and difficulty in parting with family in death. Third, most subjects experienced their religious faith as an important source of comfort and strength. SIGNIFICANCE OF RESULTS: A substantial subgroup of home hospice patients expressed problems dealing with their approaching death. These problems are amenable to psychological treatment, such as fear of death, unresolved issues, parting with family, and pain. The findings, thus, highlight the need for close collaboration of mental health professionals with home hospice institutions.

Lieberman, M. A., M. Golant, et al. (2003). "Electronic support groups for breast carcinoma: a clinical trial of effectiveness." Cancer 97(4): 920-5.
BACKGROUND: A recent Pew Charitable Trust study found that 52,000,000 individuals used the Internet to obtain health/medical information. Clinical trials of face-to-face breast carcinoma support groups show evidence of 1) improvement in quality of life, 2) reduction of psychologic symptoms, 3) improvement in coping responses, and 4) a reduction in pain. To the authors' knowledge, a few studies published to date have investigated Internet-delivered electronic support groups (ESGs) for cancer. The most sophisticated is the Comprehensive Health Enhancement Support System (CHESS) program, which provides integrated information, referral, and a newsgroup-based social support program. However, to the authors' knowledge, no studies published to date have examined the impact of a breast carcinoma ESG in a clinical trial. METHODS: Sixty-seven women completed the initial baseline questionnaires, 32 of whom accepted the authors' invitation and began the groups. With regard to geographic location, 49% lived in rural/small towns, 41% lived in medium-sized cities, and 10% lived in large cities. Diagnostic stages of disease were: Stage I, 22%; Stage II, 56%; Stage III, 12%; and other forms, 10%. There were 4 intervention groups, of which 8 participants led by trained Wellness Community (TWC) (a national agency) leaders met for 1.5 hours once a week for 16 weeks. Student t tests for paired outcome data were computed using baseline and postgroup scores. RESULTS: The results of the current study indicated that breast carcinoma patients significantly reduced depression (Center for Epidemiologic Studies-Depression [CES-D] scale) and Reactions to Pain. They also demonstrated a trend toward increases on The Posttraumatic Growth Inventory (PTGI) in two subscales: New Possibilities and Spirituality. Counterintuitively, breast carcinoma patients appeared to demonstrate an increase in emotional suppression. Postinterview results indicated that approximately 67% of patients found the group to be beneficial. Those who withdrew from the groups (20%) demonstrated low scores in their ability to contain anxiety and appeared to be more likely to suppress their thoughts and feelings regarding their illness. CONCLUSIONS: The findings of the current study are encouraging, particularly because it was conducted through TWC, a national agency willing to make this type of intervention readily available at no cost. A limitation of the current study was the lack of randomization and a control group comparison. Although the authors were not able to demonstrate effectiveness without the addition of a control condition, the analysis of pregroup and postgroup outcomes suggests that a randomized trial is worthwhile. Women with a devastating disease will join and commit themselves to an online support group. In addition, because a large percentage of these women were from rural locations, this type of intervention may hold promise for those who have limited access to support groups.

Rosenbaum, E., H. Gautier, et al. (2003). "Developing a free supportive care program for cancer patients within an integrative medicine clinic." Support Care Cancer 11(5): 263-9.
The cancer patient's journey not only includes a threat to one's life, but the need to face many medical and emotional challenges. The free Cancer Supportive Care Program (CSCP) within the Center for Integrative Medicine Clinic at Stanford University Hospital and Clinics has been identified as a successful model for helping patients to deal with these challenges. Its programs include informational lectures, support groups, chair massages, exercise, alternative modality classes, a Life Tapes Project, an informational website, and a bimonthly newsletter available free to anybody touched by cancer. Now in its third year, this program benefits from a blending of leadership resources, availability of space, institutional agreement on patient need and funds from private and corporate donations. By presenting the basic premises of the Cancer Supportive Care program and outlining specifics about the program, institutions in various national and international demographic regions may implement similar programs according to their resources and the needs of patients. It is our hope that the CSCP can become a model for the development of similar programs in various parts of the United States and abroad.

Sephton, S. and D. Spiegel (2003). "Circadian disruption in cancer: a neuroendocrine-immune pathway from stress to disease?" Brain Behav Immun 17(5): 321-8.
Psychosocial factors may modulate the course of cancer, but few data have been gathered on the biological mechanisms by which these effects may be mediated. We briefly review evidence of psychosocial effects on cancer progression and discuss one potential pathway that may underlie these effects: the disruption of neuroendocrine and immune circadian rhythms. Circadian system alterations occur in tumor tissue, tumor-bearing animals, and cancer patients with greater disruption seen in more advanced cases. Rhythm alterations include diminished amplitude, phase shifts, period changes, and erratic peaks and troughs in endocrine, metabolic, immunological, and rest- activity cycles. Psychosocial factors can engender dysregulation of circadian function. Cancer-related circadian dysregulation may also be driven by genetic factors, environmental and behavioral influences, and effects of the tumor on host clock regulation. There are several mechanisms by which circadian disruption might hasten tumor growth: via direct effects of altered hormone levels on tumor cells, effects on tumor versus host metabolism, neuroimmune effects resulting in cancer-relevant immunosuppression, or reduced efficacy and tolerability of cancer treatments for which the timing of administration is based upon the assumption of normal circadian rhythms. Emerging data in the human and animal literature suggest that circadian regulation may be an important prerequisite for the maintenance of host defenses against cancer. Thus, stress-related circadian disruption may have negative implications for cancer prognosis. Psychosocial effects on cancer progression may be measured, and possibly mediated, by disruption of circadian function.

Spiegel, D. and J. Giese-Davis (2003). "Depression and cancer: mechanisms and disease progression." Biol Psychiatry 54(3): 269-82.
Depression and cancer commonly co-occur. The prevalence of depression among cancer patients increases with disease severity and symptoms such as pain and fatigue. The literature on depression as a predictor of cancer incidence is mixed, although chronic and severe depression may be associated with elevated cancer risk. There is divided but stronger evidence that depression predicts cancer progression and mortality, although disentangling the deleterious effects of disease progression on mood complicates this research, as does the fact that some symptoms of cancer and its treatment mimic depression. There is evidence that providing psychosocial support reduces depression, anxiety, and pain, and may increase survival time with cancer, although studies in this latter area are also divided. Psychophysiological mechanisms linking depression and cancer progression include dysregulation of the hypothalamic-pituitary-adrenal axis, especially diurnal variation in cortisol and melatonin. Depression also affects components of immune function that may affect cancer surveillance. Thus, there is evidence of a bidirectional relationship between cancer and depression, offering new opportunities for therapeutic intervention.

Winzelberg, A. J., C. Classen, et al. (2003). "Evaluation of an internet support group for women with primary breast cancer." Cancer 97(5): 1164-73.
BACKGROUND: Women with breast carcinoma commonly experience psychologic distress following their diagnosis. Women who participate in breast cancer support groups have reported significant reduction in their psychologic distress and pain and improvement in the quality of their lives. Web-based breast cancer social support groups are widely used, but little is known of their effectiveness. Preliminary evidence suggests that women benefit from their participation in web-based support groups. METHODS: Seventy-two women with primary breast carcinoma were assigned randomly to a 12-week, web-based, social support group (Bosom Buddies). The group was semistructured, moderated by a health care professional, and delivered in an asynchronous newsgroup format. RESULTS: The results indicate that a web-based support group can be useful in reducing depression and cancer-related trauma, as well as perceived stress, among women with primary breast carcinoma. The effect sizes ranged from 0.38 to 0.54. Participants perceived a variety of benefits and high satisfaction from their participation in the intervention CONCLUSIONS: This study demonstrated that the web-based program, Bosom Buddies, was effective in reducing participants' scores on depression, perceived stress, and cancer-related trauma measures. The effect size of the intervention was in the moderate range. Although web-based social support groups offer many advantages, this delivery mechanism presents a number of ethical issues that need to be addressed.

Spiegel, D. and S. Sephton (2002). "Re: Night shift work, light at night, and risk of breast cancer." J Natl Cancer Inst 94(7): 530; author reply 532-3.

Spiegel, D. and S. E. Sephton (2001). "Psychoneuroimmune and endocrine pathways in cancer: effects of stress and support." Semin Clin Neuropsychiatry 6(4): 252-65.
The bulk of cancer research has productively focused on the pathophysiology of the disease, emphasizing tumor biology, especially tumor characteristics such as DNA ploidy and estrogen/progesterone receptor status as predictors of disease outcome, at the expense of studying the body's psychophysiological reactions to tumor invasion. These reactions are mediated by brain/body mechanisms, including the endocrine, neuroimmune, and autonomic nervous systems. Although a large portion of the variance in any disease outcome is accounted for by the specific local pathophysiology of that disease, some variability must also be explained by 'host resistance' factors, which include the manner of response to the stress of the illness. The evidence of links between social support, stress, emotional state, and immune and endocrine function is growing. Here we examine evidence that 2 especially promising mechanisms, one immune, one endocrine, may mediate the relationship between stress and social support on the one hand and cancer progression on the other. We chose natural killer (NK) cells and cortisol because they are particularly good examples of mediating mechanisms for which there is solid basic and clinical evidence. NK cells are of great interest because they are involved in tumor surveillance, and because their activity can be measured in vitro.

Spiegel, D. (2002). "Effects of psychotherapy on cancer survival." Nat Rev Cancer 2(5): 383-9.
The possibility that psychotherapy could extend survival time for cancer patients has attracted attention among clinical investigators interested in the mind-body connection, among cancer patients seeking the best possible outcome and among the general public. A small number of randomized trials have been conducted, and they have produced conflicting results. Does emotional support affect the course of cancer? What physiological pathways might mediate such an effect? Given what we now know, should we change the standard of care for cancer patients?

Spiegel, D. and M. Cordova (2001). "Supportive-expressive group therapy and life extension of breast cancer patients: Spiegel et al. (1989)." Adv Mind Body Med 17(1): 38-41.

Fobair, P., K. O'Hanlan, et al. (2001). "Comparison of lesbian and heterosexual women's response to newly diagnosed breast cancer." Psychooncology 10(1): 40-51.
In a study comparing lesbian and heterosexual women's response to newly diagnosed breast cancer, we compared data from 29 lesbians with 246 heterosexual women with breast cancer. Our hypotheses were that lesbian breast cancer patients would report higher scores of mood disturbance; suffer fewer problems with body image and sexual activity; show more expressiveness and cohesiveness and less conflict with their partners; would find social support from their partners and friends; and would have a poorer perception of the medical care system than heterosexual women. Our predictions regarding sexual orientation differences were supported for results regarding body image, social support, and medical care. There were no differences in mood, sexual activity or relational issues. Not predicted were differences in coping, indicating areas of emotional strength and vulnerability among the lesbian sample.

Gabler, B., G. Kroher, et al. (2001). "[Severe, bilateral vision loss in malignant melanoma of the skin. Anterior ischemic optic neuropathy with irreversible vision and visual field loss in adjuvant interferon alfa-2b therapy]." Ophthalmologe 98(7): 672-3.

Giese-Davis, J. and D. Spiegel (2001). "Suppression, repressive-defensiveness, restraint, and distress in metastatic breast cancer: separable or inseparable constructs?" J Pers 69(3): 417-49.
A longstanding hypothesis links affective and behavioral inhibition with cancer incidence and progression though it does not clarify psychometric distinctions among related constructs. We hypothesized that repressive-defensiveness, suppression, restraint, and distress would be separable factors in our sample of metastatic breast cancer patients. Our results support the discriminant validity of these constructs in our total sample, and the stability over 1 year in our control group. Using factor analysis, we found 4 separate factors at our prerandomization baseline corresponding closely to hypothesized constructs. Additionally, associations in a multi-trait, multi-occasion (baseline and 1 year) matrix met each of the 3 Campbell and Fiske (1959) criteria of convergent and discriminant validity. Future research testing the links between psychological, physiological, and survival outcomes with affective inhibition in cancer patients will be clearer when informed by these distinctions.

Koopman, C., K. Angell, et al. (2001). "Distress, coping, and social support among rural women recently diagnosed with primary breast cancer." Breast J 7(1): 25-33.
This study examined distress, coping, and group support among a sample of rural women who had been recently diagnosed with breast cancer. We recruited 100 women who had been diagnosed with primary breast cancer at one of two time points in their medical treatment: either within a window up to 3 months after their diagnosis of breast cancer, or within 6 months after completing medical treatment for breast cancer. Their mean age was 58.6 years (SD = 11.6), and 90% were of white/European American ethnicity. Women completed a battery of demographic and psychosocial measures prior to being randomized into a psychoeducational intervention study, and then again 3 months later at a follow-up assessment. The focus of this article is on the women's self-reported psychosocial status at baseline. Many of the women experienced considerable traumatic stress regarding their breast cancer. However, this distress was not reflected in a standard measure of mood disturbance that is frequently used in intervention research (the Profile of Mood States). The average woman considered her diagnosis of breast cancer to be among the four most stressful life events that she had ever experienced. Also, women on average reported a high level of helplessness/hopelessness in coping with their cancer. On average, women felt that they "often" (but not "very often") received instrumental assistance, emotional support, and informational support. Women varied considerably in which kind of social group provided them with the most support, with as many reporting that they found the greatest support in spiritual/church groups or within their family units as with breast or general cancer groups. These results suggest that among these rural women with breast cancer, distress with the diagnosis of breast cancer must be carefully assessed, as women who are highly distressed about their breast cancer may not report general mood disturbance. Furthermore, the kinds of groups that rural women with breast cancer experience as most supportive need to be identified so that psychosocial interventions can be matched to breast cancer patients' individual needs.

Mouysset, J. L., M. Baciuchka-Palmaro, et al. (2001). "[Nutritional workshops for cancer patients: a pilot approach]." Bull Cancer 88(10): 959-64.
The authors describe an original experience with 3 years of a nutritional workshop for cancer patients. This intervention combine an information about nutritional aspects of cancer with psychosocial support, to buffer psychological and nutritional consequences of cancer. The workshop, leaded by two specialized teams, one in medical oncology, the other in public health, is proposed to patients during and after a specific treatment. In one day, it provided information about nutrition and cancer, diet education and psychosocial support with supportive-expressive group. At this day, the evaluation of this intervention is only subjective. Fifty-six patients participated in at least one workshop, with majority of women (91%). Nineteen workshops were leaded with average participant number of 7 per workshop the third year. The authors believe that nutritional workshops are of great help for cancer patients, by enhancing social reinsertion, giving opportunity of emotional expression and humanizing the treatment. Our experience show it is possible to propose psychosocial intervention in institution in the context of Mediterranean country. We are leading currently a study that will permit a more systematic evaluation of the effects of this intervention.

Sephton, S. E., C. Koopman, et al. (2001). "Spiritual expression and immune status in women with metastatic breast cancer: an exploratory study." Breast J 7(5): 345-53.
This exploratory study examined relationships between spirituality and immune function in 112 women with metastatic breast cancer. Spirituality was assessed by patient reports of frequency of attendance at religious services and importance of religious or spiritual expression. White blood cell counts, absolute numbers of lymphocytes, T-lymphocyte subsets, and natural killer cells were assessed by flow cytometry. Assessments of natural killer cell activity and delayed-type hypersensitivity responses to skin test antigens provided two measures of functional immunity. In analyses controlling for demographic, disease status, and treatment variables, women who rated spiritual expression as more important had greater numbers of circulating white blood cells and total lymphocyte counts. Upon examination of relationships with lymphocyte subsets, both helper and cytotoxic T-cell counts were greater among women reporting greater spirituality.

Spiegel, D. (2001). "Mind matters -- group therapy and survival in breast cancer." N Engl J Med 345(24): 1767-8.

Spiegel, D. (2001). "Mind matters. Coping and cancer progression." J Psychosom Res 50(5): 287-90.
The idea that having an 'attitude' about cancer makes a difference in its course is a popular but controversial one. Most oncologists and surgeons believe that tumor type and stage, general health, and medical treatment are all that account for the variance in outcome. Many patients and their families believe that having the right attitude makes a difference in the course of disease. This leads us to two empirical questions: (1) Does coping make a difference in disease progression when medical prognostic variables are taken into account? and (2) What constitutes the 'right attitude'?

Giese-Davis, J., K. Hermanson, et al. (2000). "Quality of couples' relationship and adjustment to metastatic breast cancer." J Fam Psychol 14(2): 251-66.
This study examined mood disturbance among women with metastatic breast cancer in relationship to partnership status, relationship quality, and partner's coping and mood disturbance. These associations were examined within a total sample of 125 metastatic breast cancer patients and a subsample of 48 of these patients and their partners. Partnered and single women were indistinguishable in mood disturbance when household income was statistically controlled. Results also showed that patients were less distressed when they rated the relationship higher in Cohesion--Expression and in Conflict and when their partners reported lower mood disturbance. One possible implication of these results is that in relationships in which a woman has metastatic cancer, she may benefit from open engagement of difficulties and conflict. Furthermore, alleviating her distress may be better achieved by focus on the couple relationship rather than her individual coping.

Moore, R. J. and D. Spiegel (2000). "Uses of guided imagery for pain control by african-american and white women with metastatic breast cancer." Integr Med 2(2): 115-126.
Understanding the meanings patients attach to their experiences can help clinicians and researchers to more adequately address a patient's experience with cancer pain. Indeed, many patients seem to desire to and benefit from attaching meaning to the disease and its treatment. In particular, many patients are drawn to guided imagery as a tool in the management of cancer-related anxiety and pain. Using excerpts from African-American and White women's breast cancer narratives, we show that breast cancer survivors use guided imagery as a vehicle for reconnecting to the self, to make sense of their experiences with breast cancer, and as a tool for managing cancer pain. Cancer pain increases the disruption in the connection between the body and the mind that is already part of the illness experience. Guided imagery can be regarded as one response to this problem, and may be understood as an attempt to reconnect mind and body in a manner that increases the sense of control, thereby alleviating the suffering of the survivor.

Sephton, S. E., R. M. Sapolsky, et al. (2000). "Diurnal cortisol rhythm as a predictor of breast cancer survival." J Natl Cancer Inst 92(12): 994-1000.
BACKGROUND:: Abnormal circadian rhythms have been observed in patients with cancer, but the prognostic value of such alterations has not been confirmed. We examined the association between diurnal variation of salivary cortisol in patients with metastatic breast cancer and subsequent survival. We explored relationships between cortisol rhythms, circulating natural killer (NK) cell counts and activity, prognostic indicators, medical treatment, and psychosocial variables. METHODS: Salivary cortisol levels of 104 patients with metastatic breast cancer were assessed at study entry at 0800, 1200, 1700, and 2100 hours on each of 3 consecutive days, and the slope of diurnal cortisol variation was calculated using a regression of log-transformed cortisol concentrations on sample collection time. NK cell numbers were measured by flow cytometry, and NK cell activity was measured by the chromium release assay. The survival analysis was conducted by the Cox proportional hazards regression model with two-sided statistical testing. RESULTS: Cortisol slope predicted subsequent survival up to 7 years later. Earlier mortality occurred among patients with relatively "flat" rhythms, indicating a lack of normal diurnal variation (Cox proportional hazards, P =. 0036). Patients with chest metastases, as opposed to those with visceral or bone metastases, had more rhythmic cortisol profiles. Flattened profiles were linked with low counts and suppressed activity of NK cells. After adjustment for each of these and other factors, the cortisol slope remained a statistically significant, independent predictor of survival time. NK cell count emerged as a secondary predictor of survival. CONCLUSIONS: Patients with metastatic breast cancer whose diurnal cortisol rhythms were flattened or abnormal had earlier mortality. Suppression of NK cell count and NK function may be a mediator or a marker of more rapid disease progression.

Turner-Cobb, J. M., S. E. Sephton, et al. (2000). "Social support and salivary cortisol in women with metastatic breast cancer." Psychosom Med 62(3): 337-45.
OBJECTIVE: This study used a cross-sectional design to examine the relationships between social support, both quantity (number of people) and quality (appraisal, belonging, tangible, and self-esteem), and neuroendocrine function (mean and slope of diurnal salivary cortisol) among women with metastatic breast cancer. METHODS: Participants (N = 103) were drawn from a study (N = 125) of the effects of group therapy on emotional adjustment and health in women with metastatic breast cancer. They completed the Interpersonal Support Evaluation List and the Yale Social Support Index and provided saliva samples for assessment of diurnal cortisol levels on each of 3 consecutive days. Diurnal mean levels were calculated using log-transformed cortisol concentrations, and the slope of diurnal cortisol variation was calculated by regression of log-transformed cortisol concentrations on sample collection time. RESULTS: Mean salivary cortisol was negatively related to the Interpersonal Support Evaluation List subscales of appraisal, belonging, and tangible social support. No association was found between quantitative support or the esteem subscale of the Interpersonal Support Evaluation List and mean salivary cortisol. Measures of qualitative and quantitative social support were not associated with the diurnal cortisol slope. CONCLUSIONS: Results show that greater quality of social support is associated with lower cortisol concentrations in women with metastatic breast cancer, which is indicative of healthier neuroendocrine functioning. These results may have clinical implications in the treatment of breast cancer.

Whitney, S. N. and D. Spiegel (1999). "The patient, the physician, and the truth." Hastings Cent Rep 29(3): 24; discussion 24-5.

Blake-Mortimer, J., C. Gore-Felton, et al. (1999). "Improving the quality and quantity of life among patients with cancer: a review of the effectiveness of group psychotherapy." Eur J Cancer 35(11): 1581-6.
Cancer patients suffer from a number of psychosocial problems related to the progression of their disease as well as standard medical interventions. Fortunately, there is empirical evidence suggesting that group psychotherapy is effective at ameliorating psychological distress and in some cases improving survival. For this literature review we examined the psychological morbidity, particularly anxiety and depression, among cancer patients. Further, we conducted a critical examination of the current evidence regarding the effectiveness of group psychotherapy for improving the quality as well as the quantity of life in cancer patients. Finally, we explored the specific components of effective group psychotherapy, which has been associated with enhanced survival. We conclude that there is compelling evidence indicating that group psychotherapy improves the quality of life of cancer patients. Furthermore, there is a growing body of evidence suggesting that group psychotherapy improves survival of cancer patients.

Goodwin, P. J., K. I. Pritchard, et al. (1999). "The Fox guarding the clinical trial: internal vs. external validity in randomized studies." Psychooncology 8(3): 275.

Kraemer, H. and D. Spiegel (1999). "Cunning but careless: analysis of a non-replication." Psychooncology 8(3): 273-5.

Lohmann, C. P., G. Kroher, et al. (1999). "Severe loss of vision during adjuvant interferon alfa-2b treatment for malignant melanoma." Lancet 353(9161): 1326.

Spiegel, D. (1999). "A 43-year-old woman coping with cancer." Jama 282(4): 371-8.

Spiegel, D. (1999). "Embodying the mind in psychooncology research." Adv Mind Body Med 15(4): 267-73; discussion 275-81.

Spiegel, D., G. R. Morrow, et al. (1999). "Group psychotherapy for recently diagnosed breast cancer patients: a multicenter feasibility study." Psychooncology 8(6): 482-93.
As many as 80% of breast cancer patients report significant distress during initial treatment, yet there is little in the way of systematic psychotherapeutic interventions for women coping with the stress of a recent diagnosis of breast cancer. The literature on psychotherapeutic treatment of cancer patients provides uniform evidence for an improvement in mood, coping and adjustment as a result of group therapy. The present study examined the feasibility of implementing a manualized treatment, supportive-expressive group psychotherapy, in busy oncology practices across the US. This intervention was applied to women with primary breast cancer in a manner which tests not only the efficacy of the approach but also its accessibility to group therapists not previously experienced in its use. One hundred and eleven breast cancer patients within 1 year of diagnosis were recruited from ten geographically diverse sites of the National Cancer Institute's Community Clinical Oncology Program (CCOP) and two academic medical centers. Two therapists from each site were trained in supportive-expressive group psychotherapy. Training consisted of participation in a workshop, reading a treatment manual, and viewing explanatory videotapes. Each patient participated in a supportive-expressive group that met for 12 weekly sessions lasting 90 min. Assessment of mood disturbance was made at entry, 3, 6, and 12 months. Results indicated a significant 40% decrease in the Total Mood Disturbance (TMD) scores of the Profile of Mood States (POMS) (ANOVA F [2,174]=3.98, p<0.05). The total symptom score of the Hospital Anxiety and Depression Scale (HADS) was likewise significantly reduced over the 6-month period (F [2, 174]=5.2, p<0.01). Similarly, the total score of the Impact of Event Scale (IES) was significantly reduced (F [2,174]=4.0, p<0.05). There was substantial uniformity of treatment effect across sites. Outcome was independent of stage of disease (I vs. II). We conclude that this treatment program can be effectively implemented in a community setting and results in reduced distress among breast cancer patients.

Spiegel, D., H. C. Kraemer, et al. (1998). "A tale of two methods: randomization versus matching trials in clinical research." Psychooncology 7(5): 371-5.

O'Hara, R. J., J. Greenman, et al. (1998). "Advanced colorectal cancer is associated with impaired interleukin 12 and enhanced interleukin 10 production." Clin Cancer Res 4(8): 1943-8.
Interleukin 12 (IL-12) is a heterodimeric cytokine that has been demonstrated to have a major role in stimulating a cell-mediated antitumor response. IL-10, a product of T helper 2 lymphocytes, is its most potent inhibitor. The aim of this study was to investigate whether patients with colorectal cancer had an imbalance in production of IL-12 and IL-10 preoperatively, and whether this was associated with advanced disease at surgery. Blood was obtained before surgery from 60 patients with colorectal cancer and from 30 controls. Peripheral blood mononuclear cells were incubated with Staphylococcus aureus Cowan's strain 1 in vitro for 24 h to assess IL-12 expression after stimulation, and serum was used for IL-10 measurement. IL-12 and IL-10 levels were assessed by ELISA. A single pathologist staged the tumors according to the tumor-node-metastasis (TNM) and Dukes' classifications. Patients with colorectal cancer had significantly lower levels of IL-12 (P <0.001) and higher levels of IL-10(P = 0.004) compared to controls. In addition, lower levels of IL-12 were detected in those patients who were node positive (P<0.05), had Dukes' C lesions (P < or = 0.001), and T3 or T4 lesions (P<0.033) when compared to controls. Patients with Dukes' B and C lesions (P<0.01) and T3 and T4 lesions (P<0.05) also had higher levels of IL-10 compared to controls. This study is the first to demonstrate that patients with colorectal cancer have decreased IL-12 production and increased serum IL-10. This suggests an impaired T helper 1 cell-mediated antitumor response and provides some justification for exogenous IL-12 therapy or anti-IL-10 therapy in these patients.

Spiegel, D., S. E. Sephton, et al. (1998). "Effects of psychosocial treatment in prolonging cancer survival may be mediated by neuroimmune pathways." Ann N Y Acad Sci 840: 674-83.
Research has provided growing evidence of links between the social environment and cancer progression. Indeed, social support in the form of marriage, frequent daily contact with others, and the presence of a confidant may all have protective value against cancer progression. Furthermore, retrospective data suggest that major stressful life events are more prevalent in patients with relapse or malignancy, and thus may contribute to cancer morbidity. Initial studies of the effects of psychosocial intervention with cancer patients have provided some promising results. In three randomized prospective trials, protective effects of psychosocial interventions on cancer progression have been confirmed, while one matching and one randomized study showed no survival effect after psychosocial treatment. Though more research is clearly needed in this area, this body of evidence suggests that psychosocial factors have potentially powerful modulating effects on the course of disease. Here we review evidence of one possible mechanism whereby psychosocial factors may influence disease-resistance capabilities: the neuroimmune connection. Suppressive effects of stress on immune function are well documented, and these effects have been shown to be modulated by social support. Thus, it is reasonable to hypothesize that supportive social relationships may buffer the effects of cancer-related stress on immunity, and thereby facilitate the recovery of immune mechanisms that may be important for cancer resistance. Data addressing this hypothesis are reviewed.

Spiegel, D., P. Stroud, et al. (1998). "Complementary medicine." West J Med 168(4): 241-7.
The widespread use of complementary and alternative medicine techniques, often explored by patients without discussion with their primary care physician, is seen as a request from patients for care as well as cure. In this article, we discuss the reasons for the growth of and interest in complementary and alternative medicine in an era of rapidly advancing medical technology. There is, for instance, evidence of the efficacy of supportive techniques such as group psychotherapy in improving adjustment and increasing survival time of cancer patients. We describe current and developing complementary medicine programs as well as opportunities for integration of some complementary techniques into standard medical care.

Koopman, C., K. Hermanson, et al. (1998). "Social support, life stress, pain and emotional adjustment to advanced breast cancer." Psychooncology 7(2): 101-11.
The purpose of this study was to examine relationships between emotional adjustment to advanced breast cancer, pain, social support, and life stress. The cross-sectional sample was compromised of 102 women with metastatic and/or recurrent breast cancer who were recruited into a randomized psychosocial intervention study. All women completed baseline questionnaires assessing demographic and medical variables, social support, life stress, pain, and mood disturbance. Three types of social support were assessed: (1) number of persons in support system; (2) positive support; and (3) aversive support. On the Profile of Mood States (POMS) total score, we found significant interactions between life stress and social support; having more people in the patient's support system was associated with less mood disturbance, but only among patients who had undergone greater life stress. Also, aversive social contact was significantly related to total mood disturbance (POMS), and having more aversive social contact was particularly associated with total mood disturbance (POMS) among patients who had undergone greater life stress. Pain intensity was associated with greater total life stress, and was not significantly related to social support. These results are consistent with the 'buffering hypothesis' that social support may shield women with metastatic breast cancer from the effects of previous life stress on their emotional adjustment; however, aversive support may be an additional source of life stress associated with emotional distress. Also, pain is greater among women with greater life stress, regardless of social support.

O'Hara, R. J., J. Greenman, et al. (1998). "Impaired interleukin-12 production is associated with a defective anti-tumor response in colorectal cancer." Dis Colon Rectum 41(4): 460-3.
INTRODUCTION: Despite development of many chemotherapeutic regimens, colorectal cancer continues to have a high mortality. One of the major new potential therapies is interleukin-12, a heterodimeric cytokine produced by antigen presenting cells. In vitro and in vivo studies have demonstrated the role of interleukin-12 in stimulating a cell-mediated anti-tumor response against a number of colon adenocarcinoma tumor models. However, it is unknown whether patients with colorectal cancer have impaired interleukin-12 production. A study was performed to investigate production of interleukin-12 preoperatively and the relationship between these levels and disease stage at surgery. METHODS: Preoperative peripheral blood mononuclear cells from colorectal cancer patients and age-matched controls were stimulated by Staphylococcus aureus Cowan's Strain 1 (0.0075 percent wt/vol) in vitro for 24 hours. Expression of interleukin-12 was then assessed by enzyme-linked immunosorbent assay. A single pathologist assessed the tumors for stage according to TNM and Dukes classifications. RESULTS: Twenty-eight patients with colorectal cancer and 14 controls were recruited for the study. Interleukin-12 production was significantly impaired in patients with colorectal cancer compared with controls (P = 0.014), especially those with advanced disease: Dukes C, P = 0.001 and T4, P < 0.05. CONCLUSION: Interleukin-12 production is impaired in patients with colorectal cancer, especially those with advanced disease, suggesting a defective Thl-mediated anti-tumor response. These patients may well benefit from exogenous interleukin-12 treatment.

Classen, C., S. Abramson, et al. (1997). "Effectiveness of a training program for enhancing therapists' understanding of the supportive-expressive treatment model for breast cancer groups." J Psychother Pract Res 6(3): 211-8.
This study evaluated a training program for leaders of supportive-expressive psychotherapy groups for breast cancer patients. Twenty-four mental health/medical cancer care professionals completed two training phases and were tested for their understanding of the treatment model. Participants' understanding was enhanced as a result of the training program. This study demonstrates that a brief training program can improve therapists' understanding of the treatment model and demonstrates an effective method of evaluation. Future research should examine how performance on these tests generalizes to performance when leading a supportive-expressive group.

Kogon, M. M., A. Biswas, et al. (1997). "Effects of medical and psychotherapeutic treatment on the survival of women with metastatic breast carcinoma." Cancer 80(2): 225-30.
BACKGROUND: The authors previously reported a statistically significant effect of psychosocial intervention on survival time of women with metastatic breast carcinoma. In this study, the authors investigated whether this effect could be explained by differences in the medical treatment patients received subsequent to their group participation or differences in causes of death. METHODS: Of the original 86 study participants, medical treatment charts for 61 and death certificates for 83 were available for further analysis. The authors reviewed the course of the medical treatment they received subsequent to their entry into the randomized psychotherapy trial. RESULTS: Although there were no statistically significant differences with regard to chemotherapy and hormone therapy between the control and treatment groups, women in the control group tended to have received more adrenalectomies, although this procedure did not account for the difference in survival time between the control group and the treatment group. Furthermore, women in the control group developed more bone and lung metastases than the women in the treatment group. CONCLUSIONS: Differences in disease course between the control and treatment groups appeared to be independent of any differences in medical treatment received.

Spiegel, D. (1997). "Psychosocial aspects of breast cancer treatment." Semin Oncol 24(1 Suppl 1): S1-36-S1-47.
Social stress, psychological distress, and psychosocial support effect the adjustment of breast cancer patients, influence their experience of and adherence to medical treatment, and may effect the course of the disease. The literature indicates that levels of distress, depression, and anxiety are substantially elevated among patients with breast cancer. These problems persist in a sizable minority of patients even years after diagnosis. Coping styles are related to adjustment and, in some studies, survival time. The nature of the relationship with physicians affects adjustment to the illness, satisfaction with treatment outcome, and adherence to medical treatment protocols, which can influence relapse and survival. In many but not all studies, serious life stress adversely affects medical outcome. Social support in general and structured psychotherapy in particular have been shown to positively affect both adjustment and survival time. Clear and open communication, expression of appropriate emotion, and collaborative planning and problem-solving enhance adjustment and improve outcome. Conversely, influences that isolate breast cancer patients from others or undermine support can have adverse medical and psychological consequences.

Spiegel, D. and R. Moore (1997). "Imagery and hypnosis in the treatment of cancer patients." Oncology (Williston Park) 11(8): 1179-89; discussion 1189-95.
Many patients with cancer often seek some means of connecting their mental activity with the unwelcome events occurring in their bodies, via techniques such as imagery and hypnosis. Hypnosis has been shown to be an effective method for controlling cancer pain. The techniques most often employed involve physical relaxation coupled with imagery that provides a substitute focus of attention for the painful sensation. Other related imagery techniques, such as guided imagery, involve attention to internally generated mental images without the formal use of hypnosis. The most well-known of these techniques involves the use of "positive mental images" of a strong army of white blood cells killing cancer cells. Despite claims to the contrary, no reliable evidence has shown that this technique affects disease progression or survival. Studies evaluating more broadly defined forms psychosocial support have come to conflicting conclusions about whether or not these interventions affect survival of cancer patients. However, 10-year follow-up of a randomized trial involving 86 women with cancer showed that a year of weekly "supportive/expressive" group therapy significantly increased survival duration and time from recurrence to death. This intervention encourages patients to express and deal with strong emotions and also focuses on clarifying doctor-patient communication. Numerous other studies suggest that suppression of negative affect, excessive conformity, severe stress, and lack of social support predict a poorer medical outcome from cancer. Thus, further investigation into the interaction between body and mind in coping with cancer is warranted.

Spiegel, D. (1996). "Psychological distress and disease course for women with breast cancer: one answer, many questions." J Natl Cancer Inst 88(10): 629-31.

Classen, C., C. Koopman, et al. (1996). "Coping styles associated with psychological adjustment to advanced breast cancer." Health Psychol 15(6): 434-7.
The aim of this study was to determine whether psychological adjustment to advanced breast cancer was positively associated with expressing emotion and adopting a fighting spirit and negatively associated with denial and fatalism. Total mood disturbance on the Profile of Mood States was used as the measure of psychological adjustment. The Courtauld Emotional Control Scale measured emotional expression, and the Mental Adjustment to Cancer measured fighting spirit, denial, and fatalism. The sample included 101 women with a diagnosis of metastatic or recurrent breast cancer. Fighting spirit and emotional expressiveness were found to be associated with better adjustment. No association was found between mood disturbance and denial or fatalism. Because this was a cross-sectional study, no conclusions regarding a causal relationship between adjustment and emotional expressiveness or adjustment and fighting spirit were possible.

O'Hara, R. J., S. P. Dexter, et al. (1996). "Conservative management of infective mastitis and breast abscesses after ultrasonographic assessment." Br J Surg 83(10): 1413-4.
Current practice in this unit for a suspected breast abscess is preliminary ultrasonographic scan, aspiration of any pus, antibiotic therapy and repeat aspiration in the outpatient clinic if necessary. Inflammatory masses are treated with antibiotics alone. A retrospective review of this strategy has been made. Over a 2-year interval 53 patients were admitted to hospital with a suspected breast abscess. Twenty-two abscesses were aspirated, of which 19 resolved and three required subsequent incision and drainage. Eight patients underwent primary incision and drainage, one of whom required a second drainage procedure. In five patients the abscess discharged spontaneously before intervention. The remaining 18 patients were found on ultrasonography to have inflammation without evidence of focal pus which settled with antibiotic therapy in all but two patients. One of these was found to have an inflammatory cancer and the other developed an abscess, which was drained. Aspiration combined with ultrasonographic imaging is an effective alternative to incision and drainage.

Spiegel, D. and P. M. Kato (1996). "Psychosocial influences on cancer incidence and progression." Harv Rev Psychiatry 4(1): 10-26.
The impact of psychosocial factors on the incidence and progression of cancer has become an area that demands attention. In this article recent evidence of psychosocial effects on cancer incidence and progression is reviewed in the context of past research. Psychosocial factors discussed include personality, depression, emotional expression, social support, and stress. Mechanisms that could mediate the relationship between psychosocial conditions and cancer incidence and progression are also reviewed. These include alterations in diet, exercise, and circadian cycles; variations in medical treatment received; and physiological mechanisms such as psychoendocrinologic and psychoneuroimmunologic effects. We conclude that there is a nonrandom relationship among various psychosocial factors and cancer incidence and progression that can only partially be explained by behavioral, structural, or biological factors. Suggestions for future research are discussed.

Spiegel, D. (1996). "Cancer and depression." Br J Psychiatry Suppl(30): 109-16.
Half of all cancer patients have a psychiatric disorder, usually an adjustment disorder with depression. Anxiety about illness, such as cancer, often leads to delay in diagnosis, which has been estimated to reduce prospects of long-term cancer survival by 10% to 20%. Although earlier studies showed that depressed individuals were at higher risk for cancer incidence, later studies have not confirmed this predictive relationship. Nonetheless, effective psychotherapeutic treatment for depression has been found to affect the course of cancer. Psychotherapy for medically ill patients results in reduced anxiety and depression, and often pain reduction. In three randomised studies, psychotherapy resulted in longer survival time for patients with breast cancer (18 months), lymphoma, and malignant melanoma. The physiological mechanisms for these findings have not yet been determined, but four fundamental possibilities for psychotherapeutic effects on physiological change include health maintenance behaviour, health-care utilisation, endocrine environment, and immune function. Thus, effective treatment of depression in cancer patients results in better patient adjustment, reduced symptoms, reduced cost of care, and may influence disease course. The treatment of depression in these patients may be considered a part of medical as well as psychiatric treatment.

Spiegel, D. (1995). "Essentials of psychotherapeutic intervention for cancer patients." Support Care Cancer 3(4): 252-6.
Psychosocial treatments, including group, individual and family psychotherapies, are of proven efficacy, and deserve inclusion as standard components of biomedical treatment for cancer patients. Anxiety and depression are very common (and treatable) problems among cancer patients, most of whom can benefit from intervention. Psychotherapy, both group and individual, employs three fundamental approaches: emotional expression, social support, and cognitive symptom-management skills. Psychotherapy has been shown to be effective in improving quality of life. Results of studies of various psychotherapies include reduction in depression, anxiety, and pain, and improved coping skills, and, in some cases, there is evidence of extended survival time.

Spiegel, D. (1995). "How do you feel about cancer now?--survival and psychosocial support." Public Health Rep 110(3): 298-300.

Spiegel, D., S. Sands, et al. (1994). "Pain and depression in patients with cancer." Cancer 74(9): 2570-8.
BACKGROUND. Although the existence of a relationship between depression and pain in patients with cancer has been known for many years, the influence of one upon the other is still poorly understood. It has been thought that depressed individuals complain of pain more because of their psychiatric illness. Evidence from two studies indicate that pain may induce clinical depression. METHODS. In the first study, the authors examined both current and lifetime psychiatric diagnoses among patients with cancer who had high and low pain symptoms to examine the strength of the relationship between depression and cancer pain. The sample consisted of 72 women and 24 men, with 39 women and 9 men in the high pain group, and 33 women and 15 men in the low pain group. In the second study, 35 patients with metastatic carcinoma of the breast were examined for pain intensity and frequency and mood disturbance. RESULTS. The prevalence of depressive disorders of all types was found to be significantly higher in the high pain than in the low pain group across measures, 33 versus 13% (chi-square [degrees of freedom = 1] = 5.90, P < 0.05). Furthermore, there was a significantly higher history of major depression in the low pain group than in the high pain group (chi-square [degrees of freedom = 1] = 3.86, P < 0.05). Also, in comparison with patients in the low pain group, patients in the high pain group were significantly more anxious and emotionally distressed. In the second study, pain intensity correlated significantly with fatigue, vigor, and total mood disturbance, and pain frequency correlated significantly with fatigue, vigor, and depression. CONCLUSIONS. This study confirms the high concomitant occurrence of pain and psychiatric morbidity and suggests that pain may play a causal role in producing depression.

Spiegel, D. (1994). "Health caring. Psychosocial support for patients with cancer." Cancer 74(4 Suppl): 1453-7.
Psychosocial treatments, including group, individual, and family therapies, are of proven efficacy and deserve inclusion as standard components of biomedical treatment for patients with cancer. Four issues regarding such treatment are reviewed. The first is need. Significant anxiety and depression are common (and treatable) problems among the medically ill and represent a major aspect of the burden of illness. Even those with less severe emotional reactions need help coping with the stress of serious illness. The second is methods. Psychotherapy, both group and individual, provides valuable emotional and social support and teaches important symptom management skills. The third is outcome. Psychotherapy has been shown to be effective in improving quality of life and enhancing the ability of the medically ill to cope with their illness. Results of various psychotherapies include reducing depression and anxiety, improving coping skills, and in some cases, extending survival time. The fourth is cost offset. Appropriate psychotherapeutic intervention saves money by reducing unnecessary office visits, diagnostic tests, medical procedures, and hospital admittance.

Spiegel, D. (1993). "Psychosocial intervention in cancer." J Natl Cancer Inst 85(15): 1198-205.

Spiegel, D. (1992). "Conserving breasts and relationships." Health Psychol 11(6): 347-8.

Reilly, J. R., C. F. Koopman, et al. (1992). "Nasal mass in a pediatric patient." Head Neck 14(5): 415-8.
The consultants agreed that the differential diagnosis should focus on congenital masses, including an encephalocele, glioma, dermoid, hamartoma, hemangioma, rhabdomyosarcoma, neurofibroma, and nasolacrimal duct cyst. There was some disagreement as to which is the best way to evaluate the mass, ranging from an MRI (Dr. Reilly), to CT scan (Dr. Cotton), to both MRI and CT (Dr. Koopman). Blood tests to evaluate pituitary function could be indicated if there was a sphenoid defect (Dr. Reilly). None of the experts would biopsy this lesion. All would proceed with a definitive resection. One surgeon would defer surgery for several months and then perform the resection via a biocoronal craniotomy (Dr. Reilly). A combined anterior craniotomy and external ethmoidectomy would be planned by another (Dr. Koopman). The third consultant would combine an anterior craniotomy with a mid-face degloving, external rhinoplasty, or lateral rhinotomy approach (Dr. Cotton). Routine perioperative antibiotics would only be used by two of the surgeons (Drs. Reilly and Koopman). If a CSF leak were encountered there are several options. A small lesion could be allowed to close on its own (Dr. Reilly). If the leak occurred while the bicoronal incision was still open or if the leak were large, it could be repaired from above (Drs. Reilly and Koopman). One surgeon would proceed with a repair from above even if the leak were encountered during the intranasal approach (Dr. Cotton). Only one surgeon would restrict postoperative activity with intubation and sedation or paralysis (Dr. Koopman). Regarding follow-up, no one was concerned about the final pathology report.(ABSTRACT TRUNCATED AT 250 WORDS)

Spira, J. L. and D. Spiegel (1992). "Hypnosis and related techniques in pain management." Hosp J 8(1-2): 89-119.
Hypnosis has been used successfully in treating cancer patients at all stages of disease and for degrees of pain. The experience of pain is influenced not only by physiological factors stemming from disease progression and oncological treatment, but also from psychosocial factors including social support and mood. Each of these influences must be considered in the successful treatment of pain. The successful use of hypnosis also depends upon the hypnotizability of patients, their particular cognitive style, their specific motivation, and level of cognitive functioning. While most patients can benefit from the use of hypnosis, less hypnotizable patients or patients with low cognitive functioning need to receive special consideration. The exercises described in this chapter can be successfully used in groups, individual sessions, and for hospice patients confined to bed. Both self-hypnosis and therapist guided hypnosis exercises are offered.

Spiegel, D. (1990). "Can psychotherapy prolong cancer survival?" Psychosomatics 31(4): 361-6.

Spiegel, D. (1990). "Facilitating emotional coping during treatment." Cancer 66(6 Suppl): 1422-6.
Patient resources for coping with breast cancer can be enhanced by attention to cognitive, affective, psychosomatic, and social components of the illness. The diagnosis and treatment of breast cancer constitutes an immediate confrontation with mortality, and sympathetic but direct examination of the patient's vulnerability and means of coping with it will reduce rather than amplify death anxiety. The development and pursuit of realistic goals influenced by the prognosis can help patients adjust constructively. Extremes of emotion are to be expected at times, but persistent depression and/or anxiety should be vigorously treated, including the use of appropriate psychoactive medication when the symptoms are primarily somatic (e.g., sleep disturbance and reductions in energy). Physical symptoms such as pain, nausea, and vomiting can be controlled by teaching patients such techniques as self-hypnosis, biofeedback, and systemic desensitization. Finally, a feeling of social isolation is the rule, not the exception, with cancer patients. Group and family treatment can effectively counter this. Systematic studies of such treatment interventions have shown favorable results, including significant reductions in mood disturbance and pain.

Spiegel, D., J. R. Bloom, et al. (1989). "Psychological support for cancer patients." Lancet 2(8677): 1447.

Spiegel, D., J. R. Bloom, et al. (1989). "Effect of psychosocial treatment on survival of patients with metastatic breast cancer." Lancet 2(8668): 888-91.
The effect of psychosocial intervention on time of survival of 86 patients with metastatic breast cancer was studied prospectively. The 1 year intervention consisted of weekly supportive group therapy with self-hypnosis for pain. Both the treatment (n = 50) and control groups (n = 36) had routine oncological care. At 10 year follow-up, only 3 of the patients were alive, and death records were obtained for the other 83. Survival from time of randomisation and onset of intervention was a mean 36.6 (SD 37.6) months in the intervention group compared with 18.9 (10.8) months in the control group, a significant difference. Survival plots indicated that divergence in survival began at 20 months after entry, or 8 months after intervention ended.

Feldman, R. M., R. L. Gross, et al. (1989). "Risk factors for the development of Tenon's capsule cysts after trabeculectomy." Ophthalmology 96(3): 336-41.
Tenon's capsule cysts (TCCs) are a complication of glaucoma filtering surgery. They are frequently associated with substantial elevations in intraocular pressure (IOP) beginning 2 to 8 weeks postoperatively. To determine the incidence and possible risk factors for the development of TCCs, case records of all patients who received trabeculectomy over a 4-year period at the Wills Eye Hospital were reviewed. The incidence of TCCs was 28% in those who underwent trabeculectomy. Characteristics of patients after trabeculectomy in whom TCCs developed were compared with patients after trabeculectomy in whom TCCs did not develop. Both univariate and multivariate techniques were used to assess the association of characteristics associated with the development of TCCs. Factors associated with increased risk (P less than 0.05) were: history of prior TCCs, argon laser trabeculoplasty, male gender, and the use of preoperative sympathomimetics. The use of a compression shell was associated with decreased risk (P less than 0.05).

Fobair, P., R. T. Hoppe, et al. (1986). "Psychosocial problems among survivors of Hodgkin's disease." J Clin Oncol 4(5): 805-14.
The psychosocial problems that develop in long-term survivors of Hodgkin's disease were examined in a cross-sectional survey of 403 patients. The average age at treatment was 27 years and at interview was 36 years. The median time since treatment was 9 years. Sixty percent of the patients were treated for stage I or II disease and 40% for stage III or IV. Eighty-two percent of the patients had never relapsed, and 98% were free of disease at the time of interview. The study investigated the type and frequency of problems by means of a self-administered questionnaire using standard survey items to assess disruption in three areas of life: sense of well-being, family relationships, and employment. Results indicate that energy had not returned to patients' satisfaction in 37% of the cases. This was influenced by age, time since therapy, stage of disease, and type of treatment. Patients with self-reported energy loss were more likely to be depressed. Moderately high divorce rates (32%), problems with infertility (18%), and less interest in sexual activity (20%) were reported. Employment patterns favored men returning to work, and number of hours worked was highly correlated with less depression, younger age, and return of energy. Difficulties at work were reported by 42% of the cases. The interaction of treatment, biologic, psychosocial, and functional variables is described.

Shah, D., M. H. Naheedy, et al. (1985). "Intracranial vascular malformation and astrocytoma." IMJ Ill Med J 168(6): 388-90.

Spiegel, D. (1985). "The use of hypnosis in controlling cancer pain." CA Cancer J Clin 35(4): 221-31.

Bloom, J. R. and D. Spiegel (1984). "The relationship of two dimensions of social support to the psychological well-being and social functioning of women with advanced breast cancer." Soc Sci Med 19(8): 831-7.
Of interest to the field is the mechanism through which social support acts as a resistance resource for individuals undergoing stressful life circumstances. Women with advanced breast cancer (N = 86) were interviewed to determine how their outlook on life and social functioning were affected by the social support they received. Emotional support provided by the family was predicted to affect the woman's sense of well-being whereas the opportunities for social exchange provided by one's social activities were expected to effect the woman's social functioning. Consistent with the predictions, the data indicate that social support is multidimensional. Emotional support was strongly related to one's outlook. However, one's opportunities for social exchange affect not only one's social functioning, but also one's outlook on life, suggesting an interactive process whereby family support improves outlook, both outlook and opportunities for social exchange are related to one's sense of social functioning. These data explain the erosion of social support during life-threatening illness such as cancer as a result of the limitations imposed by the illness on one's opportunities for social exchange.

Spiegel, D. and J. R. Bloom (1983). "Group therapy and hypnosis reduce metastatic breast carcinoma pain." Psychosom Med 45(4): 333-9.
The pain and mood disturbance of 54 women with metastatic carcinoma of the breast were studied over the course of one year. A random sample was offered weekly group therapy during the year, with or without self-hypnosis training directed toward enhancing their competence at mastering pain and stress related to cancer. Both treatment groups demonstrated significantly less self-rated pain sensation (t = 2.5 p less than 0.02) and suffering (t = 2.17, p less than 0.03) than the control sample. Those who were offered the self-hypnosis training as well as group therapy fared best in controlling the pain sensation (F = 3.1, p less than 0.05). Pain frequency and duration were not affected. Changes in pain measures were significantly correlated with changes in self-rated total mood disturbance on the Profile of Mood States and with its anxiety, depression, and fatigue subscales. Possible mechanisms for the effectiveness of these interventions are discussed.

Spiegel, D. and J. R. Bloom (1983). "Pain in metastatic breast cancer." Cancer 52(2): 341-5.
The pain experiences of 86 women with metastatic carcinoma of the breast were systematically evaluated over a period of one year. Fifty-six percent of the sample reported experiencing pain, and the intensity of pain was not significantly related to site of metastasis. Multiple regression analysis revealed that 50% of the variance in the pain experience was accounted for by: (1) the amount of mood disturbance as measured by the Profile of Mood States (POMS); (2) the patients' belief that the pain indicated worsening of the illness; and (3) the use of analgesic medication. The nature of family support, social functioning, and coping responses were not significantly associated with pain intensity, nor was mortality during the one-year follow-up period. These data document the significance of psychological factors in accounting for differences in pain experience and document the interaction between pain and mood disturbance. These findings suggest that treatment of metastatic pain should include attention to the patient's mood and adjustment to the illness.

Spiegel, D. and M. C. Glafkides (1983). "Effects of group confrontation with death and dying." Int J Group Psychother 33(4): 433-47.

Spiegel, D., J. R. Bloom, et al. (1981). "Group support for patients with metastatic cancer. A randomized outcome study." Arch Gen Psychiatry 38(5): 527-33.
The effects of weekly supportive group meetings for women with metastatic carcinoma of the breast were systematically evaluated in a one-year, randomized, prospective outcome study. The groups focused on the problems of terminal illness, including improving relationships with family, friends, and physicians and living as fully as possible in the face of death. We hypothesized that this invention would lead to improved mood, coping strategies, and self-esteem among those in the treatment group. Eighty-six patients were tested at four-month intervals. The treatment group had significantly lower mood-disturbance scores on the Profile of Mood States scale, had fewer maladaptive coping responses, and were less phobic than the control group. This study provides objective evidence that a supportive group intervention for patients with metastatic cancer results in psychological benefit. Mechanisms underlying the effectiveness of this group intervention are explored.

Spiegel, D. (1979). "Psychological support for women with metastatic carcinoma." Psychosomatics 20(11): 780-3, 787.

Spiegel, D. and I. D. Yalom (1978). "A support group for dying patients." Int J Group Psychother 28(2): 233-45.

Koopman, C. F., Jr. and S. W. Coulthard (1979). "The role of radical neck dissection in head and neck carcinoma." Ariz Med 36(11): 829-32.

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