Medical and prognostic variables. As described briefly in the section on medical adaptive tasks, physical symptomatology and health status are often found to be strongly correlated with depression and QOL.3,31,32,34 Pain and fatigue in particular are associated with higher levels of distress.3,15 In women with metastatic breast cancer, both pain intensity and frequency have been correlated with depression and mood disturbance.43 However, as many of these studies are cross-sectional, it is not possible to determine whether pain and fatigue play a causal role in producing distress or whether depressed patients are more likely to report physical symptoms. Most likely, the relationship is bidirectional, where pain and fatigue contribute to helplessness and depression, and negative emotions exacerbate physical symptoms.
To the extent that more advanced disease is accompanied by greater physical morbidity, prognosis is likely to influence QOL. In addition, subjective perception of the severity of one's illness may be particularly important. Magnitude of perceived life threat has also been associated with QOL, where greater life threat is related to traumatic stress symptoms and impaired QOL independent of stage of disease.44 However, a study of 200 AC patients in their final weeks of life demonstrated that the prevalence of depression was three times greater among the 10% of patients who denied awareness of their terminal prognosis and foreshortened life expectancy.45 Perhaps full prognostic awareness is adaptive for some people with AC and detrimental for others, or especially critical in the final months of life, but these moderated relationships have not yet been examined.
Demographic and social contexts. The demographic variable that has most commonly been linked to adjustment is patient age, such that older patients generally report less distress and greater well-being.15,37,46-48 Older patients may have fewer competing demands on their time and resources if they are retired and have fewer caretaking responsibilities. In addition, illness in old age is more developmentally normative and consistent with expectations about how one's life will go, so a diagnosis of AC may be less distressing to this group. No evidence has been found for gender differences in adjustment to AC.49 Research on ethnic minorities is limited, but preliminary data suggest that significant disparities may exist in treatment and support services provided as well as in adjustment.50,51 The concurrent experience of other life stressors may also create a context predictive of poorer adjustment if one's intrapersonal or interpersonal resources become taxed.52
A patient's social context may be associated with their ability to adjust to AC, and investigators have examined different aspects of social support. For example, one study demonstrated that greater perceived social support was related to lower distress, even after controlling for physical health status.3 In another study, having more people in one's social support system was correlated with less mood disturbance, but only among patients who had undergone high levels of previous life stress.52 Perhaps quantity of social support is less important than the perceived quality of support, such that the number of people in one's network is less predictive than whether a patient perceives that support is available when needed. Marital status and quality have also been examined, and a study of metastatic breast cancer patients revealed that partnered women did not differ from single women in the amount of mood disturbance reported once household income was statistically controlled.53 This is consistent with other work suggesting that marital status alone is not predictive of adjustment.49 In this same study, partnered women were less distressed when their relationship was characterized by relatively high cohesion-expression and conflict, which the authors interpreted as evidence of the benefit of open engagement and communication.53 In direct contrast to this finding, a study of AC patients on hospice care and their primary caregivers found that openness about feelings was linked to greater anxiety and depression.54 Again, the effect of open communication in important relationships may be moderated by the timing of assessment and severity of disease, where openness is associated with less distress when the patient has the physical resources to actively engage in these conversations but correlated with more distress during the last weeks of life. In addition, the cross-sectional nature of these studies does not allow for causal inference, as distressed families may also be more emotionally expressive at the end of life.
Personality variables. There are relatively few investigations of the relations between personality attributes and adjustment in patients with AC, but preliminary evidence suggests that the dispositional traits of emotional expressiveness, low chronic anxiety, and optimism may predict psychological well-being. Emotional regulation styles typified by conscious suppression or lack of awareness of affect appear problematic for patients with AC. For example, high dispositional emotional control (i.e., suppression) was associated with greater mood disturbance in a study of 101 metastatic or recurrent breast cancer patients.55 Similarly, a study by Weihs and colleagues56 demonstrated that AC patients who are habitually unaware of their emotions report more negative mood states than those that are less repressive. In addition, the individuals in this sample who reported the most mood disturbance were those that were both emotionally constrained and dispositionally anxious, suggesting that the combination of repression and negative affectivity may be especially detrimental to well-being in the context of AC. In another sample of breast cancer patients, repression was not associated with high levels of self-reported anxiety and distress, but women high in repression experienced the same physiological patterns as individuals reporting high levels of anxiety (i.e., flattened diurnal cortisol slopes).57 This finding may indicate that although emotionally inhibited individuals may be unaware of their emotions, they may suffer the same maladaptive physical health consequences as chronically anxious patients.57 Overall, these findings suggest that individuals who constrain the expression or experience of their emotions may have difficultly adapting successfully to a diagnosis of AC, and the work of Giese-Davis and colleagues57 highlights the methodological challenge of assessing these individual differences.
Optimism has received support as a predictor of positive adjustment in early stage cancer (e.g., ref. 58), and this dispositional tendency to expect positive outcomes has also been found to predict well-being and enhanced emotional functioning in patients with AC.46,59 There is also interest in whether individuals with AC are more or less optimistic than cancer patients with less severe disease. Preliminary investigations have yielded conflicting results regarding this association. Miller et al.46 found that patients with AC reported greater levels of optimism than did cancer patients in other studies; however, other research suggests that levels of optimism do not correspond to disease stage.59 Gotay et al.h<9 found that optimism was correlated with enhanced emotional functioning and less depression across all stages of cancer, indicating that this personality characteristic may operate similarly throughout the course of cancer.
Coping processes. Although the effectiveness of particular coping strategies has been studied extensively in cancer patients in general, specific coping processes may be differentially related to adjustment among AC versus earlier-stage cancer patients, as individuals with AC are negotiating distinct issues. For instance, if remission of cancer is no longer a feasible goal, efforts may be focused on symptom management, grappling with end-of-life issues, and maintenance of daily functioning and social connections. Additionally, each of these goals may necessitate different coping strategies. Social and existential goals may call for strategies such as seeking social support whereas managing pain may require a problem-focused approach such as requesting a consultation with a pain specialist.
Limited research addresses the mutability of coping in the context of AC. One study sought to demonstrate how coping patterns might change throughout AC by assessing use of coping strategies every 3 months in a sample of metastatic melanoma patients.49 Any assessment completed within the last 12 months of life was analyzed. Contrary to expectation, results indicated that behaviors aimed at problem-solving such as "seeking more information about the situation" increased significantly over the final year of life. Coping through distraction and avoidance did not change, but note that those variables had very low internal consistency reliability. In another study involving a small group (n = 10) of AC patients entering a phase I trial, Sherliker et al.60 found that choice of coping strategies did vary depending upon circumstances. Specifically, patients with AC sought more social support when experiencing an acute health event (i.e., receiving treatment in the hospital) than when they were not. Additional research is needed to clarify how coping strategies might shift throughout cancer course.
Research examining the relationship between coping and adaptation is also limited. Not allowing oneself to express negative feelings (i.e., anger, anxiety, and depression) has been associated with greater mood disturbance.55 Conversely, a determined attitude focused on overcoming cancer has been associated with less mood disturbance.55,60 The effectiveness of this attitude, labeled "fighting spirit," suggests that active attempts to manage one's disease may be beneficial.
In another sample of mixed cancer patients, attempting to avoid or escape the stressor (i.e., cancer) and blaming oneself for aspects of the disease predicted increased distress over time.46 However, endorsement of the statement "I act as though it [cancer] hadn't ever happened," was correlated with positive daily mood in a small sample of patients with AC.60 Avoidance has also been associated with other aspects of adjustment such as greater satisfaction with doctor-patient communication in patients with AC.61 Notably the assessment instruments used by Miller and colleagues differed from these other studies in their measurement of behaviors such as "avoided being with people in general" that might indicate heightened distress or be maladaptive for other reasons (e.g., socially). Although the above results indicate that avoidance may be an effective coping strategy in AC, caution should be used when interpreting these findings, as there are a limited number of studies in this area and no consistent or standardized measurement of avoidant strategies. Nevertheless, in AC, putting cancer out of one's mind occasionally may provide a much-need respite from the demanding task of adapting to terminal illness, allowing survivors to function at a higher level and to enjoy life more than might be possible if they were constantly engaged with the work of adjusting to the disease.
Emotional expression, active coping, and avoidance, have all predicted positive adjustment to AC. Although seemingly counterintuitive, these results may indicate that the multifaceted issues faced by patients with AC call for diverse coping strategies. Perhaps it is best to ignore or avoid those aspects of the disease that seem overwhelming and immutable, to employ problem-focused strategies in managing controllable practical and medical issues, and to express one's emotions about uncontrollable concerns to facilitate social support and discovery of meaning. Thus, a flexible coping style allowing an individual to choose an appropriate coping strategy based upon the stressor, current health, and available psychosocial resources may be predictive of adjustment to AC. To address these questions, research will need to move beyond cross-sectional "snapshots" of coping to an experience sampling approach or other methodologies that capture the intraindividual variability in coping processes and adjustment.
Spirituality. A terminal illness prompts end-of-life concerns that may be influenced by one's spiritual, religious, or after-life beliefs. Spirituality, often described as a universal connection to the transcendent and search for meaning in life that need not be associated with a divine figure,62 appears to have a protective effect in some psychological domains for patients with AC. Self-described spiritual patients endorse less end-of-life despair, less desire for a hastened death, and more positive QOL,63-65 but not less depression or anxiety than patients who do not identify themselves as spiritual. Patients with AC who enroll in Phase I clinical trials endorse more spirituality than those who do not,64 suggesting that spirituality might influence hope or the desire to continue treatment despite advanced stage disease. Although not predictive of less depression, spirituality has been shown to moderate the effects of depression on desire for a hastened death. For instance, patients with AC who were depressed and low in spirituality indicated a greater desire for a hastened death than did patients with AC who were depressed but also identified themselves as spiritual.66 Importantly, the relationship between spirituality and well-being exists even after accounting for individual differences in after-life beliefs,65 indicating that spirituality's influence on adjustment is not simply driven by a belief in life after death.
Summary. In summary, research identifying correlates of adjustment in the context of AC is limited. The existing literature suggests that troubling physical symptoms, especially pain and fatigue, are associated with compromised psychological well-being. Evidence also suggests that older patients experience less distress than younger individuals with AC, that greater perceived social support predicts positive adjustment, and that optimism may be protective and inhibition of emotional expression deleterious for AC patients. Findings are more limited and inconclusive for the predictive utility of other demographic variables, emotional expressiveness in interpersonal relationships, coping processes, and spirituality. Finally, although this review has focused on psychosocial predictors of psychological adjustment in AC, the examination of psychosocial predictors of mortality and disease progression is gaining empirical attention (e.g., refs. 56 and 57) and provides an opportunity to test biopsychosocial models of metastatic disease.
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