Abstract
The physiological impact of a breast cancer
discussion between mothers and their daughters was
analyzed in relation to other anxiety and concern
measures. Fifty-eight mothers with varied breast
cancer histories participated. Measures of general
anxiety (BAI), concern about breast cancer (IES),
perceived risk, and observational data were
correlated to salivary cortisol and norepinephrine
measured by alpha-amylase. Analysis revealed that
cancer specific worries but not general anxiety were
positively correlated to cortisol levels, specifically
IES-intrusion subscale scores, but not IESavoidance. Observed behavioral anxiety and
avoidance during the interaction did not show
significant correlations. However, exploratory
analyses revealed whine/complain behavior to be
positively correlated with cortisol levels.
Introduction
The relationship between stress and cancer development has
not been firmly established. Large scale meta-analyses have
found only a weak connection between the two. However,
stress, especially in the minds of many women with breast
cancer, seems to have a direct connection with the
development of cancer. For example, stress was the most
attributed cause of breast cancer in a survey of 400 women
with the disease (Steward, Cheung, Duff, Wong, McQuestion,
Cheung, et al., 2001). Because of the mixed findings in the
literature with respect to the effect of psychological factors in
the progression of breast cancer, it is imperative to seek out
information to clarify the relationship
The chance for a woman in the United States of developing
breast cancer during her lifetime is one in eight. Breast cancer
is the most common cancer among women besides skin
cancer (American Cancer Society, 2007). In 2007, an
estimated 178,480 women in the United States will be
diagnosed with invasive breast cancer.
Treatments for breast cancer range from surgery to
chemotherapy and are accompanied by serious physical trials.
However, it is not only the physical effects of breast cancer
that have a dramatic influence on the women’s wellbeing.
Cancer can also be accompanied by significant emotional toil.
Depression and anxiety are often experienced by women
faced with cancer (e.g., Epping-Jordan, Compas, & Howell,
1994). Another important psychological factor is the presence
of intrusive thoughts, defined as unwanted images and strong
waves of feelings in response to a specific stressor. Intrusive
thoughts are characteristic of a post-traumatic stress response
to a cancer diagnosis or the treatment of the disease. These
uncontrollable worries are closely tied to unsuccessful efforts
to avoid or suppress unwanted thoughts or images about the
disease.
The risk of developing breast cancer can function as a choric
source of stress in women. Chronic stress has been linked to a
decrease in health. For example, a decrease in
immunocompetence puts women at an increased risk for
infectious diseases.
Primary Objective:
The focus of the current research is to better
understand the relationship between the
psychological and biological stress of women at
risk for breast cancer.
Research Questions
1. What is the relationship between the mothers’
biological stress and their general level of anxiety?
Hypothesis 1: Women who experience higher overall
anxiety will also show an increased biological response
because of an over activated stress response system.
2. What is the relationship between the mothers’
biological stress and breast cancer specific concern?
Hypothesis 2: As seen in previous studies (Gold et al.
2003, James et al. 2004) women at increased risk for
breast cancer have elevated responses to stressors. It is
hypothesized that women with increased breast cancer
concern will also have an increased stress response.
Stress Responses and Worries of Women
at Risk for Breast Cancer
Discussion and
Conclusions
Hypothesis 1: Results did not offer a replication of Bovberg
studies. General anxiety cannot be used as a predictor of
biological stress levels for women at risk for breast cancer.
Hypothesis 2: Intrusive breast cancer thoughts were found
Czarina E. Sánchez, Kate Berlin, & Bruce E. Compas
Vanderbilt University
Results
3. What is the relationship between the mothers’
biological stress response and their perceived breast
cancer risk? Hypothesis 3: Women, who perceived
their risk to be higher, will also have increased
biological stress response.
4. What is the relationship between the mother’s
biological stress and their observed anxiety and
avoidance behavior during the breast cancer
discussion? Hypothesis 4: Women who show more
anxiety and/or avoidance during the interaction will
also show an increased biological stress response.
Correlational Analyses
Hypothesis 1: No significant relationship was found between general anxiety and
biological stress levels
Hypothesis 2: A significant correlation was found between intrusion and cortisol
levels (r= 0.49 to .57 with p< 0.01) at all five time points
Method
Hypothesis 3: No significant correlation was found between perceived risk and
biological stress levels. In fact, contrary to prediction, the relationship was inverse.
Participants:
Hypothesis 4: No significant correlation was found between observed anxiety and
avoidance behavior and biological stress levels.
58 mothers ages 32 to 60 (M = 48) with their
daughters ages 11-32 (M=19)
Ethnic makeup of the sample:
71% white, 19% African American, 3%
other, 7% did not respond
Only mothers’ data was used for this study
to be positively correlated to increased cortisol stress levels.
Avoidance of those thoughts was not. A reason is that
intrusion could be considered an effect of shorter term. Since
the IES asks about symptoms in the past 7 days, women may
have been influenced to think about breast cancer because of
their participation in the study. Because the intrusive thoughts
about their risk for breast cancer had just begun, perhaps the
participants in the current study were not yet so bothered by
them to try to avoid them.
The results also have implications for psychological
treatments. The focus in any attempt to decrease stress levels,
in women at risk for breast cancer, should be on breast cancer
specific anxiety rather than general anxiety and worries.
Hypothesis 3: No relation between perceived risk and stress
was found. Using a measure with more reliability would be
an improvement to the design.
An explanation for the lack of positive correlation is that
perceived risk is not a measure of worry. A woman can
believe she will develop breast cancer, but that does not mean
she is worried about it. The indication of a negative
relationship seen in the analysis could be due to women, who
perceive their risk to higher, being more proactive in learning
and dealing with their risk. In this way, they are less stressed
dealing with the disease.
Hypothesis 4. No relation between behavioral and
physiological anxiety was found. A reason might be that the
women are not even realizing their own sensitivity to the
topic of breast cancer so their stress was seen in their
physiological response but not on their physical behavior. The
significant correlation between whine/complain and cortisol
levels was an unexpected finding which points to a very
specific behavior and stress biology relationship.
Measures:
Biological Stress
Salivary assays of cortisol and -amylase (as a
measure of nor epinephrine)
Future studies could be improved in several ways. A larger
sample would undoubtedly make the power of the analysis
greater and the effects easier to recognize. Another way
would be to have a breast cancer task along with a traditional
laboratory stress task to elicit stronger stress responses. The
discussion did not provide acute reactivity and therefore the
progress of the stress response could not be assessed. By
doing a combination, the effects of the breast cancer
discussion and the biological reactions of an acute stressor
could be better analyzed.
General Anxiety
Beck Anxiety Inventory (BAI)
Intrusive and Avoidance thoughts
Impact of Event Scale (IES) with subscales:
Avoidance
Intrusion
Perceived Risk
Assessment of risk question
How likely are you to develop breast cancer?
Observed Anxiety and Avoidance
Iowa Family Interaction Rating Scales coding
system for video taped breast cancer
interaction
References
Anxiety- participant’s emotional distress
conveyed as anxiety, nervousness, fear, tension,
stress, worry, concern, and embarrassment in
behavior
Avoidance- extent to which the participant averts
her gaze and/or orients her body away from the
other person as to avoid interaction
Gold, S.M., Zakowski, S. G., Valdimarsdottir,
H.B., & Bovberg, D.H. (2003). Stronger
endocrine responses after brief psychosocial
stress in women at familial risk of breast
cancer. Psychoneuroendocrinology, 28, 584-593
James, G.D., van Berge-Landry, H.,
Valdimarsdottir, H. B., Montgomery, G. H., &
Bovberg, D. H. (2004). Urinary catecholamine
levels in daily life are elevated in women at
familial risk of breast cancer.
Psychoneuroendocrinology, 29, 831-838.
Procedure:
Questionnaires
Participants were asked to provide information
for the psychological measures previous to
the lab visit
Laboratory visit
Mother and daughter were video taped as they
engaged in a 15 minute discussion on their
thoughts and feelings about breast cancer.
Salivary samples were drawn before the
interaction and at four later time points
Steward, D.E., Cheung, A.M., Duff, S., Wong, F.,
McQuestion, M., Cheung, T., et al. (2001).
Attributions of cause and recurrence in longterm breast cancer survivors. Psych-Oncology,
10, 179-183.
** correlation significant at p< 0.01