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Psychosocial Predictors of Survival in Metastatic Melanoma

From the Medical Psychology Unit and Department of Cancer Medicine, University of Sydney, Sydney, and Sydney Melanoma Unit, Royal Prince Alfred Hospital, Camperdown, Australia.

Address reprint requests to Phyllis Butow, PhD, Medical Psychology Unit, Royal Prince Alfred Hospital, Camperdown NSW 2050, Australia; email medpsych{at}mail.usyd.edu.au

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: Research interest in psychosocial predictors of the onset and course of cancer has been active since the 1950s. However, results have been contradictory and the literature is noted for methodologic weaknesses. In this prospective study, we aimed to systematically obtain data on psychosocial factors associated with human response to illness.

PATIENTS AND METHODS: One hundred twenty-five patients with metastatic melanoma completed questionnaires measuring cognitive appraisal of threat, coping, psychologic adjustment, perceived aim of treatment, social support, and quality of life (QOL). Questionnaires were completed, where possible, every 3 months for 2 years after diagnosis. Survival was measured from date of study entry to date of death or was censored at the date of last follow-up for surviving patients.

RESULTS: In a multivariate Cox regression analysis of baseline data, which controlled for demographic and disease predictors, the psychologic variables of perceived aim of treatment (P < .001), minimization (P < .05), and anger (P < .05) were independently predictive of survival. Patients who were married (P < .01) and who reported a better QOL (P < .05) also survived longer.

CONCLUSION: The prognostic significance of psychologic and QOL scores remained after allowance for conventional prognostic factors. If these associations reflect an early perception by the patient or doctor of disease progression, then measures are at least valuable early indicators of such progression. If psychologic processes have a more direct influence on the course of the underlying illness, then it may be possible to manipulate them for therapeutic effect. We are now conducting a randomized controlled trial of a psychologic intervention to further elucidate these issues.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
MELANOMA IS A COMMON disease. In New South Wales, Australia (population, 6.1 million; latitude, 28°S to 38°S), 2,367 people were diagnosed with melanoma and 347 people died from the disease in 1995.¹ Although the prognosis is good for those diagnosed early with small tumors, those with metastatic melanoma have an expected median survival of less than 1 year.² However, there is a wide variation in the progress of metastases, and some patients with metastatic disease survive considerably longer than might be expected. The Sydney Melanoma Unit at Royal Prince Alfred Hospital, the primary treating facility in New South Wales, Australia, which sees on average 110 patients with metastatic melanoma per year, has reported eight "extraordinary" survivors, who were apparently cured of visceral metastatic melanoma.³ Their disease and demographic profiles and treatment were indistinguishable from those of the majority of patients who survived for a much shorter period. Patient self-assessment of quality of life (QOL) was shown to be a major independent prognostic factor for survival duration in patients who received chemotherapy for metastatic melanoma,⁴ which suggests a role for psychologic factors in disease outcome.

There has been an interest in psychosocial predictors of the onset and course of cancer since the beginning of recorded medicine.⁵ The development of methodologically sound epidemiologic designs in the 1950s sparked a renewed interest in this area. Further work in psycho-neuro-immunology throughout the 1960s to 1990s demonstrated intriguing associations between the neuroendocrine system and psychosocial variables, as well as links between immunologic functioning and malignant growth.⁶

Research in the area has, however, produced contradictory results. Some prospective studies found no relationship between psychosocial factors and outcome in patients with cancer,^7,8 while others reported that psychologic factors were more predictive of outcome than known biologic prognostic factors.^2,9 Longer survival time has been associated with positive psychologic characteristics, such as a "fighting spirit,"¹⁰ outgoing personality,¹¹ denial (and the related concept of optimism),¹² and a low level of emotional distress and complaints.¹³ Derogatis et al,¹⁴ however, found that longer-term survivors were characterized by greater distress, with high levels of anxiety, hostility, and alienation.

Two randomized controlled trials have recently produced a higher level of evidence for an association between psychosocial factors and outcome. Speigel et al¹⁵ reported that women with metastatic breast cancer randomized to a psychosocial intervention group survived for twice as long as those who received standard treatment. Fawzy et al¹⁶ reported significant changes in immunologic parameters that correlated highly with changes in emotional functioning, in patients with primary melanoma randomized to an intervention group.

The confusion in the literature may be due in part to the complexity of cancer itself, but there are also widespread methodologic problems in this research, including samples that are too small and/or heterogeneous, failure to control for cancer stage, severity and symptomatology, reliance on a single assessment of psychosocial status, inadequate definition and measurement of psychosocial concepts, and use of inappropriate or improper statistical analysis.

We therefore set out to explore psychosocial predictors of outcome in metastatic melanoma by prospective evaluation of correlations between a battery of psychosocial factors and outcome in patients with metastatic melanoma.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
The study population consisted of patients with metastatic melanoma seen for the first time at the Sydney Melanoma Unit, Royal Prince Alfred Hospital, between 1991 and 1995. Exclusion criteria included inability to speak English, co-existing psychiatric illness, and extreme morbidity.

Patients were contacted by letter soon after their diagnosis and invited to participate in the study. Participating patients completed a series of questionnaires, which were repeated where possible every 3 months for up to 2 years after the diagnosis; however, in this article, we use only the initial questionnaire from each patient. Subsequent articles will explore the impact of longitudinal data on survival. Disease and demographic data were obtained from medical records. At the study close, follow-up status was determined through a search of computerized and paper-based medical records and, where necessary, by contact with the patient's general practitioner.

Psychosocial Assessment
Measures used represent an attempt to systematically obtain data on the range of significant psychosocial factors thought to be associated with human responses to illness. These measures have proven psychometric status and applicability to the cancer population.

Coping. Coping is the process of managing demands (external or internal) that are appraised as taxing or exceeding the resources of the person. We used a self-report adaptation of the Weisman and Wordon General Coping Strategies Scale, the COPE,¹⁷ which measures the use of 15 coping strategies. The COPE has been used successfully with cancer patients and has been shown to be sensitive to age, diagnosis, and staging. Patients indicate on a 5-point Likert scale the frequency with which they use each coping style (never to always). Factor analysis of the COPE in this sample yielded three factors: active, distractive, and avoidant coping. Cronbach alphas for the three factors were 0.72, 0.52, and 0.3, respectively. Active coping included "seeking more information about the situation" and "doing anything I can do, such as meditation." Distractive coping included "trying to forget, putting it out of my mind" and "living life with a new intensity, doing everything I've been meaning to do." Avoidant coping included "drinking, eating or taking drugs to feel less tense" and "being on my own a lot, keeping the feelings inside." Scores on factor 1 ranged from 3 to 15, on factor 2, from 5 to 25, and on factor 3, from 4 to 20, with a high score indicating frequent use of that coping style.

Psychologic adjustment. This concept is defined as the functional outcome of coping, including maintenance of emotional equilibrium, acceptance of the illness, and maintenance of positive self-esteem. Psychologic adjustment was measured here by the 53-item Psychological Adjustment to Cancer Scale, developed by our group.¹⁸ The sensitivity of this scale has been demonstrated in a randomized controlled trial of the use of the word cancer and euphemisms for it.¹⁹ A factor analysis in this sample resulted in a shorter, 24-item, three-factor scale, measuring stigma/isolation, minimization, and anger. Chronbach alphas for the three factors were 0.81, 0.65, and 0.69, respectively. Stigma/isolation items included "recently I have felt that I do not have much to be proud of" and "since getting cancer my body has felt unclean" (range, 14 to 70). Minimization items included "having cancer is not making any difference to my life at all" and "the thought of having treatment does not worry me" (range, 7 to 35). Anger items included "cancer is the worst thing that has ever happened to me" and "I am constantly asking myself the question—Why me?" (range, 9 to 45). Patients indicated on a 5-point Likert scale the degree to which they agreed or disagreed with each statement. High scores indicate positive adjustment.

Social support. Most definitions of social support emphasize its function in providing multidimensional aid (practical and emotional) and, as such, acting as a protective buffer during stressful periods. We used a cancer-specific measure, the Multidimensional Support Scale (MDSS).²⁰ This scale has 26 items and measures aid received from a key family member, friend, and medical practitioner nominated by the patient. Patients indicate both how often they received support (never, sometimes, often, or very often) and how often they would have preferred to receive that support (more often, less often, or it was just right). Scores ranged from 0 to 100 for each support source, with high scores indicating more frequent support.

QOL. QOL was measured using the GLQ-8 linear analog self-assessment scales, which measure eight physical and emotional responses reported by patients as the most serious side effects of chemotherapy,²¹ and the single-item Perceived Ability to Cope With Illness Scale (PACIS). These scales were found to have high reliability and criterion validity in a sample of 166 cancer patients.²² The GLQ-8 is summed to provide a total QOL score, which ranges from 8 to 800, with a high score indicating high QOL. Similarly, a high score on the PACIS (range, 0 to 100) indicates a greater perceived ability to cope.

Perceived aim of treatment. Patients' perceptions of the aim of their treatment were measured at the initial assessment only, using a single item. Patients chose from among four response options: complete cure, increased long-term survival, increased short-term survival, and reduction of symptoms. In an earlier study in which this item was piloted, this question appeared in two forms: patients were asked, first, what the doctor had told them was the aim of treatment and, second, what they thought was the aim of treatment. Because responses to the two questions were identical in all cases, the first question was not used in the current study. Nonetheless, this question does not necessarily represent an accurate portrayal of what the doctor told the patient; indeed, a number of studies have demonstrated that patients and oncologists do not usually report similar perceptions of prognosis, with patients generally displaying a pronounced optimism bias.^23,24 Rather it is thought that patients report their own perceptions of prognosis regardless of the wording of the question.

Disease and demographic variables. The following demographic and disease variables were recorded: age, sex, marital status, ethnicity, quality of spoken English, education level, occupation, date of first diagnosis of melanoma, details of the primary tumor (tumor thickness, ulceration, Clarke's level of invasion and mitosis), dates of metastases, sites of metastases, and recent treatment received.

Statistical Analysis
In this article, we explore the relationship between survival and psychosocial variables measured at baseline. In subsequent articles, we will explore the impact of longitudinal data on survival. The date of study entry was defined as the date on which the first questionnaire, with the signed consent form, was completed. Survival was measured from the date of study entry to the date of death, or was censored at the date of last follow-up for surviving patients. Differences between participants and nonparticipants were explored using Student's t test or ² test of association, as appropriate. Descriptive statistics were used to describe the final sample. Univariate Cox regression analyses were conducted to explore the relationship between demographic, disease, and psychologic variables and time to death. In these analyses, patients who reported the aim of treatment to be complete cure or increased long-term survival were contrasted with those who reported it to be increased short-term survival or reduced symptoms. Survival curves were prepared by the product-limit method and compared using the log-rank test.²⁵ Correlations between variables that were found to be significant predictors of survival in the univariate analyses were explored using the Pearson correlation coefficient. Multivariate analysis was undertaken using Cox regression,²⁶ while best subsets of explanatory variables were selected according to the methods of Lawless and Singhal.²⁷ All calculations were performed using the SPIDA statistical package (the Statistical Laboratory, Macquarie University, New South Wales, Australia).

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
One hundred twenty-five (54%) of 233 eligible patients agreed to participate in the study. Participants and nonparticipants did not differ in age (t test, 0.17; P = .866), sex (² test, 3.11; P = .07), or marital status (² test, 5.3; P = .37). However, because nonparticipants had a higher prevalence of liver and brain metastases (² test, 9.6; P < .05) and were closer to death at the time they were invited to join the study (log-rank test, 14.41; P < .0001), there was almost certainly a bias toward patients who were less ill participating in the study. The distinguishing characteristics of participating and nonparticipating patients are summarized in Table 1.

The sample patients were primarily Australian-born with a range of metastatic sites. Two thirds of the sample were male and one third was female. Demographic and disease details of the participants are shown in Table 2.

Univariate Cox regression analyses were conducted to explore the relationship between the demographic, disease, and psychologic variables listed above and time to death. The univariate results are presented in Table 3. Table 4 shows correlations between variables found to be significant in univariate analyses. Not surprisingly, moderately high correlations were found between some of the psychologic variables (for example, the correlation between minimization and anger was 0.62); however, correlations between psychologic and physical variables were low.

Variables found to be significant in univariate analyses were modeled in a multivariate Cox regression analysis. These included the psychologic measures of perceived aim of treatment, anger, and minimization, the disease variables of sites of metastases, treatment received in the past 3 months, and QOL measures (GLQ-8 and PACIS), as well as the demographic variables of marital status and education. The best subset of explanatory variables is shown in Table 5. The psychologic variables of perceived aim of treatment, minimization, and anger, as well as the QOL measure perceived effort to cope, were independently associated with survival.

Patients who perceived the aim of their treatment to be cure or long-term prolongation of life and who minimized the impact of cancer on their lives and reported greater anger about their illness survived longer. Patients who viewed their treatment goal as positive made up 90.5% of survivors versus 71.2% of nonsurvivors. The survival graph for perceived aim of treatment is shown in Fig 1. Those who reported that their illness was not difficult to cope with, who were married, and who reported an overall better QOL also survived longer.

View larger version (16K): [in this window] [in a new window]   Fig 1. Survival graph of perceived aim of treatment.

Because perception of treatment goal had emerged as a strong predictor of outcome, we explored correlates of this variable. Table 6 shows characteristics of patients who viewed the aim of treatment as cure/long-term survival versus those who viewed it as short-term survival/palliative. There were no significant differences between the two groups on any of the disease and demographic details measured, which suggests that this may be a response style independent of the disease process. We then repeated the multivariate analysis to include all disease variables (notably the details of the primary melanoma). The results remained substantially the same.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
This study explored psychosocial predictors of outcome in 125 patients with metastatic melanoma. When we controlled for demographic and disease variables reported in the literature to be predictive of outcome, five psychosocial variables measured at study entry were independently prognostic of time to death. The greatest protective effect was conferred by a belief that treatment would lead to cure or long-term survival and by marital status. For those patients who were positive about the outcome of their treatment (ie, who thought treatment would cure them or prolong their life long term), the risk of dying was reduced by 65%. Similarly, for patients who were married, the risk of dying was reduced by 50%. Two aspects of psychologic adjustment were also protective. Patients who reported that their melanoma did not greatly affect their day-to-day life survived significantly longer than those who felt it was having a big impact on their lives, and those who exhibited greater levels of anger about their situation survived longer. Finally, QOL scores were also significantly predictive of outcome.

Perceived aim of treatment had the greatest impact on survival. A number of explanations may be offered for these findings. First, perhaps the most likely explanation is that patients' responses to this item reflected what their oncologist had told them and that oncologists based this advice on signs and symptoms not recorded as prognostic features in the database and possibly not perceived by the patients themselves. It would have been interesting to compare patient reports on the aim of treatment with that proffered by their treating physician. Unfortunately, these data were not collected. All disease features currently regarded as prognostic for outcome in metastatic melanoma were recorded and checked thoroughly; however, when more is known about this disease and more refined measurements of medical and treatment variables are available, it will be possible to explore further this explanation for our findings.

A second explanation is that patients who regarded the aim of their care as short-term survival or palliation experienced signs and symptoms of their disease that are not currently regarded as prognostic indicators but that nevertheless heralded a more rapid decline. If this were so, then perhaps patient perceptions may lead us to more precise measurements of prognosis. However, this explanation is not supported by the fact that scores for patients with different perceptions of the aim of their treatment did not differ on the GLQ-8, a measure of perceived level of symptoms and distress, or on the PACIS, which measures perceived effort required to cope with the disease. Indeed, scores did not differ on any of the disease parameters measured, such as site of metastases or Clarke's level.

A third explanation is that patients who reported that treatment would lead to cure or long-term survival also exhibited an optimistic coping style and that this psychologic response to metastatic melanoma had a direct effect on the disease process. If this were so, then interventions designed to promote optimism and to minimize the impact of disease may be able to significantly extend patients' lives.

There is substantial literature linking optimism with psychosocial adjustment in the medical context and emerging data concerning the effect of optimism on outcome.²⁸ For example, optimism predicted psychologic adjustment 1 day before surgery for early-stage breast cancer and at 3-, 6-, and 12-month follow-up, when investigators controlled for previous well-being.²⁹ Similarly, the related concept of denial has been linked with survival in cancer.³⁰

Possible mechanisms for the effect of optimism have been suggested, including its influence on neuroendocrine functioning, choice of coping style (active rather than passive), health behaviors (eg, diet or compliance with treatment), and ability to elicit positive social support and avoid depression. There are also well-articulated theories concerning the origin of optimism. Some data suggest a genetic influence. For example, Schulman et al¹² found that interclass correlations for optimism in dizygotic twins was 0, compared with 0.48 in monozygotic twins. Others have emphasized the causative role of attribution,³¹ suggesting that people who attribute bad events to their own mismanagement, who expect bad events to occur in the future, and who generalize their experience to a broad range of events are likely to be more pessimistic. The latter explanation suggests an avenue for intervention, which is significant if the results reported above are to be tested in a randomized controlled trial.

If the relationship between perceived aim of cure and outcome is mediated by patient optimism, then methods of increasing hope and optimism deserve attention. In fact, there has long been an effort among physicians to promote hope in their patients, in the belief that it will assist in adjustment and prolong life.³² In a recent survey of the views of cancer patients concerning communication strategies that encourage hope, Sardell and Treiweiller³³ found that a collaborative approach to decision making and an enthusiastic pursuit of treatment options were favored, whereas nondisclosure was believed to reduce hope. It is certainly unethical to promote false hope. However, pointing out to patients the possibility that they may be the one in 10 or the one in 100 who do better may allow them to maintain hope while also maintaining a realistic view of their situation.

The significant finding for marital status is in line with the considerable literature linking social support to disease outcome.³⁴ Interestingly, our specific measure of the amount and adequacy of cancer-related social support was not predictive of survival, which suggests that the contribution of spouses was more subtle. However, a relatively high rate of missing data (17%) on the social support measure may also have reduced its sensitivity. In comparison, all patients completed the measures of psychologic adjustment and QOL. The social support measure, with its questions about the level and adequacy of support, seemed to be overly complex and lacking in face validity for patients.

The two aspects of psychologic adjustment found to be predictive (minimization and anger) are similar to those reported by Greer et al³⁵ to significantly predict survival (denial and fighting spirit) and supports their importance not only in early-stage disease but also in advanced cancers. These coping strategies seem to move the patient away from the passive, helpless/hopeless stance that has been associated with shorter survival.

The significant, although limited, impact of QOL on survival is an important finding because of the now widespread inclusion of QOL measures in clinical trials. These data underscore the importance of QOL as an outcome measure in drug trials and also suggest that QOL should be controlled for in assessments of the survival advantage of different drugs.

One limitation to the external validity of the current study was the sample bias introduced by the significantly longer survival time of participants compared with nonparticipants. It is possible that the role of perception of treatment goal and other psychosocial factors as significant predictors of survival is limited to those patients with a better prognosis; in the poorer-prognosis group, medical indicators may have played a more powerful role.

We are now conducting a randomized controlled trial of an individual psychologic intervention, designed to increase realistic optimism and minimize the impact of cancer on patients' lives, with patients with metastatic melanoma. We are seeking to establish (1) whether optimism and coping are malleable and (2) whether increasing optimism will lead to a survival advantage.

	ACKNOWLEDGMENTS

 
Supported by grants no. 910733 and 940419 from the National Health and Medical Research Council of Australia

We acknowledge the contributions of Anne Tunks, Paul Tunks, Simone Parsons, Sally Girgis, Robyn Miller, and Judy Brown in collecting and managing the data for this project.

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
1. Nguyen HL, Coates MS, Armstrong BK: Cutaneous Melanoma in NSW in 1983 to 1995. Kings Cross, NSW, Australia, NSW Cancer Council, 1997

2. Coates AS: Systemic chemotherapy for malignant melanoma. World J Surg 6:277-281, 1992

3. Coates AS, Segelov E: Long term response to chemotherapy in patients with visceral metastatic melanoma. Ann Oncol 5:249-251, 1994[Abstract/Free Full Text]

4. Coates AS, Thomson D, McLeod GR, et al: Prognostic value of quality of life scores in a trial of chemotherapy with or without interferon in patients with metastatic melanoma. Eur J Cancer 29a:1731-1734, 1993

5. Jensen AB: Psychosocial factors in breast cancer and their possible impact upon prognosis. Cancer Treat Rev 18:191-210, 1991[Medline]

6. Levenson JL, Bemis C, Presberg BA: The role of psychological factors in cancer onset and progression: A critical appraisal, in Lewis CE, O'Sullivan C, Barraclough J (eds): The Psychoimminology of Cancer: Mind and Body in the Fight for Survival. Oxford, United Kingdom, Oxford University Press, 1994

7. Cassileth BR, Walsh WP, Luske EJ: Psychosocial correlates of survival in advanced malignant disease. J Clin Oncol 6:1753-1759, 1988[Abstract/Free Full Text]

8. Jamison RN, Burish TG, Wallson KA: Psychogenic factors in predicting survival of breast cancer patients. J Clin Oncol 5:768-772, 1987[Abstract/Free Full Text]

9. Ruckdeschel JC, Piantadosi S, the Lung Cancer Study Group: Quality of life assessment in lung surgery for bronchogenic carcinoma. Theoret Surg 6:201-205, 1991

10. Greer S: Psychological response to cancer and survival. Psychol Med 21:43-49, 1991[Medline]

11. Stavraky KM, Donner AP, Kincade JE, et al: The effect of psychosocial factors on lung cancer mortality at out year. J Clin Epidemiol 41:75-82, 1988[Medline]

12. Schulman P, Keith D, Seligman ME: Is optimism heritable? A study of twins. Behav Res Ther 31:569-574, 1993[Medline]

13. Weisman AD, Worden JW: The existential plight in cancer: significance of the first 100 days. Int J Psychiatry Med 7:1-15, 1976[Medline]

14. Derogatis LR, Abeloff MD, Melsanratos P: Psychological coping mechanisms and survival time in metastatic breast cancer. JAMA 242:1504-1508, 1979[Abstract/Free Full Text]

15. Speigel D, Bloom JR, Kraemer HC, et al: Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet ii:888-891, 1989

16. Fawzy FI, Fawzy NW, Hyun CS, et al: Malignant melanoma: Effects of an early structured psychiatric intervention, coping and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 50:681-689, 1993[Abstract/Free Full Text]

17. Weisman AD, Wordon JW: The existential plight in cancer: Significance of the first 100 days. Int J Psychiatry Med 7:1-15, 1976

18. Dunn SM, Welch GW, Butow PN, et al: Refining the measurement of psychological adjustment in cancer. Aust J Psychol 49:144-151, 1997

19. Dunn SM, Patterson PU, Butow PN, et al: Cancer by another name: A randomized trial of the effects of euphemism and uncertainty in communicating with cancer patients. J Clin Oncol 11:989-996, 1993[Abstract/Free Full Text]

20. Neuling SJ, Winefield HR: Social support and recovery after surgery for breast cancer: Frequency and correlates of supportive behaviours by family, friends and surgeon. Soc Sci Med 27:385-392, 1988

21. Coates AS, Glasziou PP, McNeil D: On the receiving end: III. Measurement of quality of life during cancer chemotherapy. Ann Oncol 1:213-217, 1990[Abstract/Free Full Text]

22. Butow PN, Coates AS, Dunn S, et al: On the receiving end: IV. Validation of quality of life indicators. Ann Oncol 2:597-603, 1991[Abstract/Free Full Text]

23. Gattellari M, Butow PN, Tattersall MH, et al: Misunderstanding in cancer patients: Why shoot the messenger? Ann Oncol 10:39-46, 1999[Abstract/Free Full Text]

24. Mackillop WJ, Stewart WE, Ginsberg AD, et al: Cancer patients' perceptions of their disease and its treatment. Br J Cancer 58:355-358, 1988[Medline]

25. Peto R, Pike MC, Armitage P, et al: Design and analysis of randomised clinical trials requiring prolonged observation of each patient: I. Introduction and design. Br J Cancer 34:585-612, 1976[Medline]

26. Cox DR: Regression models and life tables (with discussion). J R Stat Soc B34:187-220, 1972

27. Lawless JF, Singhal K: Efficient screening of nonnormal regression models. Biometrics 34:318-327, 1978

28. Scheier MF, Carver CS: Effects of optimism on psychological and physical well being: Theoretical and emptical update. Cognit Ther Res 16:201-228, 1992

29. Carver CS, Harris SD, Robinson DS, et al: Optimism versus pessimism predicts the quality of women's adjustment to early stage breast cancer. Cancer 73:1213-1220, 1994[Medline]

30. Greer S, Moris T, Pettingale KW: Psychological response to breast cancer: Effect on outcome. Lancet ii:785-787, 1979

31. Peterson C, Seligman ME: Explanatory style and illness. J Pers 55:237-265, 1987[Medline]

32. Oken D: What to tell cancer patients: A study of medical attitudes. JAMA 175:1120-1128, 1961

33. Sardell AN, Treiweiller SJ: Disclosing the cancer diagnosis: Procedures that influence patient hopefulness. Cancer 72:3355-3365, 1993[Medline]

34. Ortmeyer CF: Variations in mortality, morbidity and health care by marital status, in Enhardt CE, Berlin JE (eds): Mortality and morbidity in the United States. Cambridge, MA, Harvard University Press, 1974, pp 159-588

35. Greer S, Morris S, Pettingale KW, et al: Psychological response to breast cancer and 15 year outcome. Lancet 335:49-50, 1990[Medline]

Submitted June 1, 1998; accepted February 24, 1999.

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