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© 2003 American Society for Clinical Oncology Dispositional Optimism Predicts Survival Status 1 Year After Diagnosis in Head and Neck Cancer PatientsFrom the Faculty of Dentistry, McGill University, Montreal, Canada, and the Department of Otorhinolaryngology and Cervico-Facial Surgery, Centre Hospitalier Universitaire, Clermont-Ferrand, France. Address reprint requests to P. J. Allison, BDS, PhD, Faculty of Dentistry, McGill University, 3640, University Street, Montreal, Quebec, Canada H3A 2B2; email: paul.allison{at}mcgill.ca.
Purpose: The aim of this study was to investigate the hypothesis that, independent of other known prognostic factors, pessimistic head and neck (H&N) cancer patients have a greater risk of being dead 1 year after diagnosis than do optimistic patients. Patients and Methods: A prospective observational study design was used with a cohort of H&N cancer patients diagnosed during the period from March 1, 1997, to August 31, 1998, at the Centre Hospitalier Universitaire, Clermont-Ferrand, France. Dispositional optimism (DO) was evaluated at baseline using a French version of the Life Orientation Test translated and validated for this study. One-year survival status was collected on all subjects. The analysis of the hypothesized association between DO and 1-year survival was performed using multiple logistic regression analysis, controlling for other sociodemographic and clinical variables. Results: The sample size was 101 patients, representing all but one of those patients fitting the inclusion criteria who were diagnosed during the recruitment period. Of these, 51 were alive at 1 year after diagnosis, 45 were dead, and five were lost to follow-up. The multivariate analysis was performed on the data from the 96 subjects in whom 1-year survival status was known. Controlling for known predictors of H&N cancer survival, pessimistic subjects (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.01 to 1.24) and those living alone (OR, 4.14; 95% CI, 1.21 to 14.17) were more likely than optimistic subjects and those living with others to be dead at 1 year. Conclusion: The results of this study of a cohort of French H&N cancer patients indicate that dispositional optimism predicts 1-year survival independent of other sociodemographic and clinical variables.
PERSONALITY CAN greatly affect an individual’s overall physical well-being. The connection between the mind and the body has stimulated much discourse, and it has been clearly documented that individuals who exhibit pessimistic attitudes have poorer physical health,1 are prone to depression,2 and are subject to higher mortality rates.3 Most recently, a systematic review of the predictive relation between patients’ recovery expectations and their health outcomes found that 15 of 16 articles on the subject with "moderate-quality evidence" showed that positive expectations were associated with better outcomes.4 It would seem that those individuals who possess the internal will to attain personal goals and anticipate the best possible outcome are able to lead longer and healthier lives. Hence, with the onset of disease, these individuals are able to exhibit a better prognosis and outcome than their more pessimistic counterparts.5–7 In the field of cancer care, a number of studies have demonstrated an association between patients’ positive expectations and various indicators of cancer therapy outcome, particularly with respect to breast cancer.6–13 Furthermore, some psycho-educational interventions designed to improve therapeutic outcomes have shown definite benefits in terms of both psychosocial outcomes and disease recurrence and survival.14–17 However, there is, as yet, no consensus in the literature concerning the effects of such interventions as a result of the differing study designs, measurement techniques, and data analyses used.18,19 With respect to head and neck (H&N) cancer, the lack of studies investigating the link between psychosocial factors of any kind and therapeutic outcomes is striking. However, all of the few studies published on the subject have shown a positive association between psychosocial factors and treatment outcomes. A prospective investigation19 of psychosocial and physical correlates of survival and recurrence in a cohort of 133 Dutch H&N cancer patients found that patients with high physical self-efficacy and strong expression of psychosocial complaints before therapy had better survival and less recurrent disease, compared with their non-self-efficacious and noncomplaining peers. Another Dutch study20 of a cohort of 208 H&N cancer patients found cognitive functioning and marital status to be predictive of recurrent disease and survival. Finally, in a previously published analysis of short-term results from our study,21 we reported that dispositional optimism was associated with a number of quality-of-life domains (as measured by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30.) in a cohort of 101 H&N cancer patients both before and then 3 months after treatment. This work, and that concerning breast cancer and other health problems (coupled with the observation that, despite investment in research investigating myriad therapeutic regimes and biologic prognostic indicators, survival among H&N cancer patients has not improved during the last 25 years22), indicate that further investigation of the role of psychosocial factors as predictors of H&N cancer survival could be an important avenue of research. In view of these observations, the aim of this study was to investigate the role of dispositional optimism as a predictor of 1-year survival in a cohort of H&N cancer patients. More specifically, we hypothesized that, controlling for known prognostic indicators, more pessimistic patients would be more likely to be dead 1 year after diagnosis than would more optimistic patients.
Study Design To be eligible, subjects had to be newly diagnosed with an H&N cancer (International Classification of Diseases, Ninth Revision [ICD-9] 141-9, and 161), have no previous history of any form of cancer, and be able to understand and complete the study questionnaires. Subjects were all recruited at the Centre Hospitalier Universitaire, Clermont-Ferrand, France, during the period from March 1, 1997, to August 31, 1998. A prospective, observational study design was used, with the study cohort being followed for a period of 1 year after study entry. All independent variable data were collected at the time of recruitment into the study, 1 to 2 weeks after diagnosis, and before treatment. Survival status was collected at 1 year after diagnosis. Ethical approval of the study was given by the appropriate hospital review board.
Sample
Variable Measurement Dispositional optimism. Dispositional optimism was evaluated using the FLOT,23 a questionnaire with 12 items, four of which are so-called filler items to disguise the purpose of the questionnaire. These filler items make no contribution to the evaluation. All items are in the form of a statement concerning the subject’s attitudes. The responses are in the form of a five-category Likert scale (strongly agree to strongly disagree). Of the eight active items, four are stated positively and four negatively. The Life Orientation Test (LOT) generates one score through a simple summing of the item scores, giving a possible range of 0 to 32, with high scores indicating a greater degree of optimism. Although the LOT has been used in a number of other studies investigating dispositional optimism in clinical settings,6,24 it has not been translated and validated in French. We therefore undertook translation and validation of a French version of the LOT as part of this study, details of which are included in a previous publication.21 Translation was performed using the multiple forward and backward translation protocol recommended by Guillemin et al.25 This FLOT was given to all 101 study participants at baseline to facilitate an evaluation of internal reliability through the generation of interitem correlation coefficients and Cronbach’s  (as recommended by Streiner and Norman26). It was also given a second time, 1 week later, to a convenience subsample of 47 of the original group to facilitate evaluation of external (test-retest) reliability through the generation of the intraclass correlation coefficient (ICC; as recommended by Streiner and Norman26). The interitem and the item-total score Pearson correlation coefficients for the FLOT are listed in Table 2 . (The item numbers are equivalent to those used in the original publication23 with the filler items removed.) The majority of these correlation coefficients are medium to high, although those with respect to item 3 are consistently poor. We have therefore included item-total score correlation coefficients for a version of the FLOT without item 3 (the FLOTb). Cronbach’s for the FLOT was 0.66, and that for the FLOTb was 0.71. The ICC for the FLOT was 0.55, and that for the FLOTb was 0.63. In view of the superior psychometric properties of the FLOTb compared with the FLOT, the former (ie, a French language, seven-active-item version of the LOT, with a possible range of 0 to 28) was used in all subsequent data analyses in addition to the eight-item FLOT. However, this made little difference in the findings, and so only those results concerning the eight-item FLOT are reported.
Quality of life variables. After the previous work alluded to in the introduction, we also included cognitive function and an overall evaluation of quality of life (QOL) as possible predictors of survival. The cognitive function and global domains of the EORTC QLQ-C30 were used to evaluate these variables. QOL was evaluated at baseline; that is, at the same time as all other independent variable data were collected. Other variables. Independent sociodemographic (age, sex, and cohabitation status) and clinical (disease stage, disease site, comorbidity, and treatment modality) variables were also collected at baseline, and survival status (the dependent variable) was collected 1 year after diagnosis.
Statistical Analyses
The results of the bivariate analyses of the relationship between independent variables and 1-year survival are listed in Tables 3 (sociodemographic and clinical variables)  and 4 (self-rated QOL and dispositional optimism variables). It is evident that a number of the variables are significantly associated with survival status or show a strong tendency toward such an association. Among the sociodemographic variables, age and cohabitation status were related to survival at the bivariate level of analysis. With respect to age, subjects in the youngest quartile had significantly increased odds to not survive the first year compared with the two middle-quartile groups, and they had a strong tendency for a similar relationship with those in the oldest quartile. Those subjects living alone had increased odds for not surviving the first year following diagnosis. Those subjects with pharyngeal cancers had significantly increased odds for not surviving 1 year compared with their peers with laryngeal cancer, whereas the odds for survival for those with an oral cancer lay between those for the other two sites. The odds for survival were also associated with disease stage, with increasing odds for death at 1 year being associated with later disease stage at diagnosis. This is made evident through a dose-response effect for increased odds for death with increased disease stage and with a significantly increased OR for death with later stage disease (OR, 3.1; 95% confidence interval [CI], 1.27 to 7.57) when that variable was dichotomized into early (stages I and II) versus late (stages III and IV) stage (see Table 3). For the bivariate level of analysis illustrated in Table 4, the QOL variables were categorized initially into quartiles of the possible range of domain scores (0 to 100). Then, as a result of the skewed distribution of the domain scores, the cognitive function domain was dichotomized into those with scores of 0 to 50 versus those with scores of 51 to 100. This was done in a previous study reporting cognitive function to be associated with survival in H&N cancer patients,20 in which the distribution of this variable was similarly skewed. Similarly, the global domain was dichotomized around the upper and lower halves of the possible domain scores. Odds and ORs were calculated for both forms of categorization, and neither cognitive function nor global QOL was associated with survival status in this sample. Finally, with respect to the relationship between FLOT scores and survival status, again as a result of the skewed distribution of the scores, an initial analysis based on categories of quartiles of the actual range of scores was supplemented with one in which the sample was dichotomized into the lowest quartile versus the second, third, and fourth quartiles. This was done in view of the observation that the odds for dying in the higher three quartiles were similar to each other and were much lower than those of the first quartile. The latter analysis indicated increased odds for death for those with FLOT scores of 5 to 17; that is, the more pessimistic subjects.
The results of the subsequent multivariate analysis are listed in Table 5
We have performed a study to test the hypothesis that H&N cancer patients rating themselves as more pessimistic are less likely to survive 1 year after diagnosis of their cancer than are patients who rate themselves as more optimistic. The results of this study support this hypothesis. This study adds to the growing body of work indicating that psychosocial factors can have an important effect on the outcome of cancer treatments, independent of the well-known and strong influences of biologic factors such as disease stage.
To the best of our knowledge, this is the only study to have investigated the link between dispositional optimism and patient survival in a sample of H&N cancer patients, so comparison with other studies needs to be performed judiciously. The study that most closely mirrors ours is that of de Boer et al,19 in the Netherlands, who prospectively observed a cohort of 133 H&N cancer patients and reported that patients evaluating themselves as physically self-efficacious and those who expressed intense psychosocial complaints before treatment had lower rates of recurrence and better survival rates than others. Physical self-efficacy concerns patients’ perceived physical abilities and confidence, and it was evaluated using a modification of the Physical Self-Efficacy Scale.27 Examples of items are, "I am not agile and graceful" and "I have physical defects that sometimes bother me." From this brief description, it is evident that the construct is different from that of dispositional optimism, the basis for the LOT. The psychosocial complaints in the aforementioned study were evaluated through the psychosocial problem scale of the Rotterdam Symptom Checklist,28 an example of which is, "during the past three days I suffered from worrying." Although this could be said to be closer to dispositional optimism than physical self-efficacy, it really concerns emotional well-being rather than a general attitude to life and personality characteristics, as Scheier and Carver23 described dispositional optimism. However, the recognition and expression of how one feels about ill health are seen to be positive features associated with being better able to cope and taking a more active role in managing that illness.19,29–31 In this sense, the findings of our study support the latter Dutch study, in that optimism is thought to be associated with more positive coping strategies and better health outcomes.32,33 Another study concerning H&N cancer patients found that patients with less than optimal cognitive function, as measured by that domain in the EORTC QLQ-C30, were at greater risk for recurrent disease and of death.20 Once again, however, this is different from optimism, because the cognitive function items in the EORTC QLQ-C30 are concerned with problems with concentration and memory.34 We investigated the role of cognitive function and global QOL as predictors of survival in our own study, but we found no association. However, the combination of the smaller sample size in our study, and the skewed distribution of the cognitive function domain scores in particular (see Table 4 Beyond H&N cancer, the link between optimism, measured using the LOT or an adaptation of the LOT, and better health outcomes, including cancer survival, has been demonstrated in a number of previous studies.6,8,9,12 In a review of the possible explanations of links between psychological factors and biologic body responses, Cohen and Herbert35 reported that there is substantial evidence that factors such as stress, negative effect, depression, social support, and repression/denial are associated with both cellular and hormonal indicators of immune status and function. However, they also concluded that our understanding of the relationship between psychology and biology in relation to the onset and progression of diseases such as cancer is far from complete.35 The second interesting finding of this study, which supports previous work in H&N cancer and other cancers and diseases, is that cohabitation was independently associated with survival in this group. Those subjects living alone were at increased odds to not survive the first year (OR, 4.14; 95% CI, 1.21 to 14.17). This is in agreement with one of the aforementioned Dutch studies of survival in H&N cancer, which found that married subjects were more likely to survive,20 and with studies of people with other cancers that have demonstrated decreased survival in unmarried persons.36,37 There are many possible explanations for the observation that people living alone do worse than those living with someone, ranging from psychological and emotional support to help with feeding and access to health care and various therapeutic regimes.38 Finally, in discussing the findings of this study, it is important to recognize its limitations. Possibly the most important of these is the instrument used to evaluate dispositional optimism and the timing of its use. With respect to the timing of the FLOT’s application in this study, all subjects received the questionnaire at the equivalent treatment planning appointment, 1 to 2 weeks after diagnosis. However, the timing of this appointment was not exactly the same relative to biopsy and diagnostic appointments for all subjects, so it is possible that this timing affected how people rated themselves with the FLOT. With respect to the instrument itself, although the original LOT has demonstrated reasonable psychometric properties as a measure of optimism in certain U.S. patients and other groups, we had to translate the LOT into French and revalidate that translation. However, we followed recommended translation procedures and evaluated the FLOT’s psychometric properties to some extent. The results of these analyses are reported in more detail elsewhere;21 in essence, the internal consistency was good, but the test-retest reliability was not so good, which obviously raises questions concerning the reliability of the FLOT and/or the stability of the trait being measured. Dispositional optimism is thought to be a stable personality characteristic,23 which indicates that the reliability of the instrument is in question. A comparison of our data with those of Carver et al,6 when they used the LOT with breast cancer patients, shows that they reported a test-retest reliability of 0.74, which is better than that in our study (0.55), although still not exceptional. Other limitations of the study concern its small sample size and heterogeneous nature, which included oral, pharyngeal, and laryngeal cancer patients and those undergoing a variety of treatment regimes. We did control for these variables in the analyses, but an ideal study would perhaps restrict subjects to one cancer site. In addition, we did not collect data on subjects’ Karnofsky performance status, socioeconomic status, smoking status, or biologic markers of prognosis other than disease stage. Although this is a limitation of the study, it should also be recognized that the literature concerning predictors of H&N cancer survival is, with the exception of disease stage, inconsistent. For instance, even limiting the field to recent clinic-based studies like ours reveals factors such as smoking status as a predictor of survival present in one19 but not in another.20 It is evident that large, well-designed prospective studies involving a number of centers and countries are required to clarify exactly which factors predict survival in this group. Finally, there is the issue of the five subjects lost to follow-up. We did compare the data from this group with those of the other 96 patients, but no differences were found, although this may have been attributable to the small size of the group lost to follow-up. Considering this observation, it is unlikely that the addition of data from this group would have made a significant difference to our overall findings. In conclusion, the findings of this prospective study in a cohort of French H&N cancer patients support the hypothesis that more pessimistic patients are less likely to be alive 1 year after diagnosis than are their more optimistic peers, independent of other known, biologic prognostic indicators.
We acknowledge the financial support of La Coopération France-Québec and the Canadian Institutes of Health Research in the performance of this research.
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
