Personal growth and psychological distress in advanced breast cancer.

Abstract

The experience of posttraumatic growth following breast cancer, its association with psychological distress and the predictive value of psychological distress, sociodemographic and clinical characteristics of cancer patients in their personal growth.
The Posttraumatic Growth Inventory and the Greek version of the Hospital Depression and Anxiety Scale (G-HADS) were administered to 100 breast cancer patients. Sociodemographic and clinical characteristics were recorded.
The analysis showed that significant associations were found between PTGI-Total patients' age (p=0.001), and being married (p=0.007). Moreover, significant negative association was observed between PTGI-II ("New Possibilities") and HADS-Depression (r=-0.314, p<0.05). Multiple regression analyses showed that age is a significant predictor of PTGI-II ("New Possibilities") (p=0.005), PTGI-V ("Appreciation of Life") (p=0.0005) and PTGI-Total (p=0.037), while marital status is a significant predictor of PTGI-Total (p=0.009).
Specific patients' characteristics, such as young age and being with a partner, influence the experience of posttraumatic growth in breast cancer patients.

Full text

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Original article
Personal growth and psychological distress in advanced breast cancer
Kyriaki Mystakidoua,*, Eleni Tsilikaa, Efi Parpaa, Dimitrios Kyriakopoulosb,
Nikos Malamosc, Dimitrios Damigosb
aPain Relief and Palliative Care Unit, Department of Radiology, Areteion Hospital, School of Medicine,
University of Athens, 27 Korinthias Street, 115 26 Athens, Greece
bLaboratory of Medical Psychology, University of Ioannina, Ioannina, Greece
cGynaecological Oncology Unit, ‘‘Elena Venizelos’’ Hospital, Athens, Greece
Received 21 November 2006; received in revised form 10 January 2008; accepted 17 January 2008
Abstract
Aims: The experience of posttraumatic growth following breast cancer, its association with psychological distress and the predictive value of
psychological distress, sociodemographic and clinical characteristics of cancer patients in their personal growth.
Methods: The Posttraumatic Growth Inventory and the Greek version of the Hospital Depression and Anxiety Scale (G-HADS) were adminis-
tered to 100 breast cancer patients. Sociodemographic and clinical characteristics were recorded.
Results: The analysis showed that significant associations were found between PTGI-Total patients’ age (p ¼ 0.001), and being married
(p ¼ 0.007). Moreover, significant negative association was observed between PTGI-II (‘‘New Possibilities’’) and HADS-Depression
(r ¼ ?0.314, p < 0.05). Multiple regression analyses showed that age is a significant predictor of PTGI-II (‘‘New Possibilities’’)
(p ¼ 0.005), PTGI-V (‘‘Appreciation of Life’’) (p ¼ 0.0005) and PTGI-Total (p ¼ 0.037), while marital status is a significant predictor of
PTGI-Total (p ¼ 0.009).
Conclusion: Specific patients’ characteristics, such as young age and being with a partner, influence the experience of posttraumatic growth in
breast cancer patients.
? 2008 Elsevier Ltd. All rights reserved.
Keywords: breast cancer; Posttrauma growth; Palliative care; Anxiety; Depression
Introduction
Breast cancer is the most common malignant disease in
women. It is estimated that in the year 2006 more than
210,000 women will have been found to have breast cancer
in the United States and more than 40,000 will have died
from the disease.1There has been an extensive investigation
into the negative psychological, physical and social conse-
quences of cancer.2Many scholars have noted that theory,
research, and practice have failed to investigate the affirmative
aspects of mental health such as resilience, wellness, and ful-
fillment, except when considering the absence of the
pathological.3
However, there are data concerning more positive aspects
of adjustment following a malignant disease that may exist.
Many cancer survivors attribute positive outcomes or personal
benefits to the cancer experience, including enhanced life ap-
preciation, improved relationships with others, and positive
changes in self-concept.4Sears et al5have found that 83%
of women diagnosed with breast cancer, perceived at least
one benefit from their experience.
These findings in cancer populations join a larger literature
suggesting that the effects of traumatic and stressful experi-
ences are not uniformly negative and that various stressors in-
cluding health problems6may be associated with profound
positive consequences. Tedeschi and Calhoun7,8have coined
* Corresponding author: Tel.: þ30 21 0770 7669; fax: þ30 21 0748 8437.
E-mail addresses: mistakidou@yahoo.com (K. Mystakidou), silentsilika@
yahoo.com (E. Tsilika), eparp@yahoo.gr (E. Parpa), kyriakopoulos_dim@
yahoo.gr (D. Kyriakopoulos), nikosmalamos@yahoo.gr (N. Malamos),
damigos@cc.uoi.gr (D. Damigos).
0960-9776/$ - see front matter ? 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.breast.2008.01.006
Available online at www.sciencedirect.com
The Breast 17 (2008) 382e386
www.elsevier.com/locate/breast

Page 2

the term ‘‘posttraumatic growth’’ (PTG) to refer to the positive
changes in life philosophy, relationships and personal growth
that people frequently attribute to having endured a stressful
or traumatic experience.
Tedeschi and Calhoun’s7model also specifies a prominent
role for characteristics of the individual, such as the coping ef-
forts that they use to manage the event, in the emergence of
PTG. Coping efforts that include accepting the impact of the
stressor, taking active steps to improve one’s circumstances,
and reframing the event in a positive light. They may create
opportunities for personal growth by encouraging reevaluation
of the meaning of the stressor in the context of one’s life and
also by prompting the revisions in priorities, relationships, and
the self that constitute PTG. Acceptance, positive reinterpreta-
tion, and active coping have been linked to higher levels of
PTG in the literature.5
Currently, there are three interrelated, cutting-edge trends in
mental health research: (a) the positive psychology move-
ment,9,10(b) the recognition of the role of spirituality and reli-
gion in health and well-being, and (c) stress-related growth.
The third trend is the recent attention given to human capacity
fortransformationineventhe direst ofcircumstances.11Thein-
tegration of these trends into mainstream studies of trauma will
provide a counterbalance to the predominant orientation of vic-
timization and pathology currently evidenced in the literature.
Each of these three trends provides opportunities to more
completely understand survivors of trauma by balancing the
traditional focus on the negative and pathological aspects
with attention to the potentially positive aspects of protection,
resilience, and growth that many survivors also experience.3
The aims of the present study were to investigate the rela-
tionship between posttraumatic growth and psychological dis-
tress (as measured by the Hospital Anxiety and Depression
Scale), as well as the influence of psychological distress to pa-
tients’ posttraumatic growth.
Materials and methods
The current study was performed from May to July 2006.
One hundred and eleven patients with advanced breast cancer
(stage IV, using the TNM system) attended the outpatient
oncology unit of Helena Venizelos Hospital (n ¼ 70) and the
palliative care unit of the Areteion Hospital (n ¼ 41) in
Athens. Of these patients 11 did not participate in the study
either due to refusal, or due to inability to communicate (4 pa-
tients). The final sample consisted of 100 consecutive patients
suffering from incurable cancer. Criteria for inclusion were:
histologically confirmed malignancy, age >18 years, ability
to communicate effectively with the health-care professionals,
patient’s signed informed consent, and knowledge of the dis-
ease diagnosis. Patients were excluded if there was a history
of drug abuse and a diagnosis of a psychiatric disorder. Re-
search workers recorded data on disease status, and treatment
regimen. Disease status information included cancer diagnosis
and performance status as defined by the Eastern Cooperative
Oncology Group (ECOG).12Treatment regimen data consisted
of whether the patient had undergone radiotherapy or
chemotherapy. Patients also completed the Hospital Anxiety
and Depression Scale (HADS), a measure specifically de-
signed for use with general medical and surgical patients,13
which is particularly appropriate for cancer patients.14
The study was performed in accordance with the Helsinki
Declaration and according to European guidelines for good
clinical practice, and was approved by the Institution’s ethical
review board.
Instruments
ThePosttraumaticGrowthInventory(PTGI)wasusedinorder
to investigate posttraumatic growth among Greek advanced can-
cerpatients.PTGIconsistsof21itemswhichareincludedinfive
major factors: F1 ¼ ‘‘Relating to others’’ (7 items), F2 ¼ ‘‘New
Possibilities’’ (5 items), F3 ¼ ‘‘Personal Strength’’ (4 items),
F4 ¼ ‘‘Spiritual Change’’ (2 items), F5 ¼ ‘‘Appreciation of
Life’’(3items).Response choices rangingfrom0(‘‘Ididnotex-
periencethischangeasaresultofmycrisis’’)to5(‘‘Iexperienced
this change to a very great degree as a result of my crisis’’). The
total score of PTGI is the sum of the five factors.8The internal
consistency of the total PTGI was a ¼ 0.90.
TheHospitalAnxietyandDepressionScale(HADS)wasalso
used to measure patients’ distress. It is a self-assessment mood
scale specifically designed for use in hospital departments. It
hasbeenshownthatitgivesclinicallymeaningfulresultsasapsy-
chological screening tool, in clinical group comparisons, and in
studies with several aspects of disease and quality of life.15It is
briefandlimited tothetwomost common aspects ofpsycholog-
icaldisorderspresentinginhospitalpractice:anxietyanddepres-
sion. Each of the two subscales, HADS-A (anxiety) and HADS-
D (depression), consist of seven items, each of them rated on
four-point (0: no problems to 3: maximum distress) scales by
the researchers.13Evidence is presented that the scale scores
are not affected by the presence of bodily illness.13In their orig-
inal study the authors recommend three cut-off scores for both
subscales: 0e7, non-cases; 8e10, doubtful cases for either anx-
iety or depression (with possible ranges of 0e21 for each sub-
scale); and ?11, cases. Many investigators have interpreted
HADS as a bidimensional instrument, assessing anxiety and de-
pressionindependently,16,13sowehavedecidedtousethisinter-
pretation in the present study. The HADS scale has been
standardizedandvalidatedinasampleofadvancedGreekcancer
patients (G-HADS), proving it a useful screening measure for
anxiety and depression in this sensitive patient population.17
Statistical analyses
Descriptive statistics including means, standard deviations,
percentages, and counts for the variables were calculated. A
Univariate analysis was performed using Pearson’s correla-
tions coefficient and independent samples t-test. A multiple
regression model (Enter method) was used with PTGI five fac-
tors scores and total score as the dependent variables, and age,
marital status, level of education, time and number of metas-
tases, and radiotherapy as the predictor variables. Regression
model assumptions were evaluated using residuals-based
383
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diagnostic procedures. Statistical significance for all analyses
was set at 0.05.
Results
Descriptive statistics
Most of the patients were primary school graduates, and the
majority was married (74%). Ninety-nine percent of partici-
pants HADS undergone chemotherapy, and mean time since
diagnosis was 6.11 ? 5.0 years (Table 1). The mean score on
posttraumatic growth was 43.76 (SD ?16.21). HADS-Anxiety
mean score was 7.36 ? 3.51 (range: 1e16) and HADS-De-
pression mean score was 6.18 ? 3.59 (range: 0e17) (Table 2).
Univariate analyses
According to the t-test, patients of younger age reported
a higher level of posttraumatic growth concerning total score
of Growth (p ¼ 0.001) and factors II, III, and V (‘‘New
Possibilities’’, p < 0.001, ‘‘Personal Strength’’, p ¼ 0.035,
‘‘Appreciation of Life’’, p < 0.001). Moreover, posttraumatic
growth was higher in married patients compared to those
with no partner (p ¼ 0.007 for Growth Total, p ¼ 0.042 for
‘‘Relating to Others’’, p ¼ 0.048 for ‘‘Spiritual Change’’ and
p ¼ 0.041 for ‘‘Appreciation of Life’’) (Tables 3 and 4). There
were no statistically significant associations between PTGI
and time and number of metastasis, radiotherapy, chemother-
apy and education level. On the other hand, there was
a moderate correlation between PTGI-II (‘‘New Possibilities’’)
and depression (r ¼ ?0.314, p < 0.05). No significant correla-
tions were found between PTGI-Total, its scales and anxiety,
and HADS-Total (Table 4).
Multivariate analyses
A multiple regression model (Enter method) was conducted
toexaminetheuniquecontributionofthedemographicvariables
(age,maritalstatus,education),clinicalvariables(timeandnum-
ber of metastases, radiotherapy), and psychological distress
(anxiety and depression), for the prediction of posttraumatic
growth and its factors. The analyses resulted in a significant
model (F ¼ 3.668, p < 0.001) explaining 31.4% of thevariance
for the prediction of ‘‘New Possibilities’’ (PTGI-II). Age
(p ¼ 0.005) was significant predictor of ‘‘New Possibilities’’.
For the prediction of ‘‘Appreciation of Life’’ (PTGI-V), the
model (F ¼ 3.176, p ¼ 0.001) explained 28.4% of the variance.
Younger age (p ¼ 0.000) was the only significant predictor of
‘‘AppreciationofLife’’.Finally,forthepredictionofPTGI-Total
the model (F ¼ 2.082, p ¼ 0.030) explained 20.7% of the vari-
ance. Younger age (p ¼ 0.037) and marital status (p ¼ 0.009)
were significant predictors of PTGI-Total (Table 5).
Discussion
We are in the midst of a paradigm shift in psychology from
a discipline primarily concerned with pathology to a new
model of psychological health and thriving.9,10This new
framework may have particular relevance for people dealing
with life-threatening diseases such as cancer.18Positive
changes following adversity have long been recognized in phi-
losophy, literature, and religion.19
The mean score of growth in the present sample was 43.76
(SD ?16.21), on a possible range of 0 to 105. This score is
Table 3
Correlations between PTGI-Total and patients’ age and marital status (t-test)
Table 1
Patients’ demographic and clinical characteristics (n ¼ 100)
Age (years)
Mean ? SD 58.2 ? 11.9
Age ?60
Age >60
Range 31e81
60
40
Marital status
Partner
No partner
74
26
Education level
Primary
High school
University
43
38
19
Time since
diagnosis (years)
Mean ? SD 6.11 ? 5.0
Metastasis time (years)
<5
?5
Number of metastases
1
?2
Radiotherapy
Yes
No
Range 0e28
61
39
50
50
71
29
Chemotherapy
Yes
No
99
1
Table 2
Descriptive statistics of the assessed instruments
Rangemean ? SD
43.76 ? 16.21
15.01 ? 6.89
4.77 ? 4.47
11.07 ? 4.40
5.15 ? 3.34
7.65 ? 4.24
7.36 ? 3.51
6.18 ? 3.59
13.54 ? 6.32
PTGI-T
PTGI-I
PTGI-II
PTGI-III
PTGI-IV
PTGI-V
HADS-Anxiety
HADS-Depression
HADS-Total
13e96
3e34
0e21
1e20
0e10
0e15
1e16
0e17
3e31
PTGI-Total
p Value
Age0.001
?60 (n ¼ 60)
>60 (n ¼ 40)
Marital status
Partner
No partner
48.05 ? 17.07
37.33 ? 12.47
0.007
46.32 ? 15.92
36.46 ? 15.02
384
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considerably lower than that found in other studies, e.g. the
mean scores reported by Cordova et al.4(mean 64.1, SD
?24.8) and Manne et al.20(mean 55.7) in samples of breast
cancer patients. Jaarsma et al.21studied posttraumatic growth
in a heterogeneous group of cancer patients and find a mean
score of 47.9. The lower score in our sample is probably
due to the fact that participants are of older age, and the low
scores in both anxiety and depression. In addition the
advanced stage of the disease may influence perception of
growth. Similarly to our results, Lechner et al.22have found
that patients with stage IV disease report lower levels of
growth, suggesting that advanced cancer forms a threat that
may overwhelm the individual’s capacity to find benefit in
a life-threatening event.
The present study found that younger women reported the
highest levels of growth in all domains (p ¼ 0.001 for growth
Table 5
Multiple regression analyses (Enter method)
total). This finding is consistent with the results of Manne
etal.20aswellasBelizziandBlank,23whoalsofoundthatyoun-
gerageisrelatedtoperceivedgrowthinwomenwithbreastcan-
cer. Researchers who have examined perception of growth in
breast cancer patients suggest that younger age is associated
with increased reports of growth, as it seems that an amount of
time is required for cognitive processing.4,24,25A possible ex-
planation of this finding is that having breast cancer is more
threatening and more distressing for younger women. The
greater threat may prompt more growth. In addition, younger
women may be more positive in re-evaluating and redefining
their life goals and priorities influenced by the disease, com-
pared to older women who have formed their beliefs because
of significant life events other than the cancer experience.
The findings related to marital status are consistent with
Belizzi and Blank’s23study that having a partner is related
to psychological growth (p ¼ 0.007, for total growth). Being
married appears to be an important factor in women’s percep-
tions of posttraumatic growth. Patients dealing with a traumatic
experience like cancer may recognize their vulnerability and
become more emotionally expressive and willing to accept
help. A committed partner can offer a beneficial support to
help cope with, or enhance the patient’s situation.21
Theassociationbetweenpsychologicaldistressandthecourse
of growth is still unclear. Greater levels of perceived threat and
harm are associated with higher levels of posttraumatic growth.
However,theredoesnotappeartobeaconsistentlypositivelinear
relationbetweenthedegreeofdistressandgrowth.26Researchers
have observed relationships between posttrauma growth and
higher levels of well-being.27Some researchers suggest thatper-
ception of positive outcomes and depressive symptoms are not
mutually exclusive, as they represent different constructs that
cancoexist,21whileothershavefoundasignificantassociation.28
Inthepresentstudydepressionhadasignificantnegativecorrela-
tion with PTG-II (‘‘New Possibilities’’). No other growth factor
correlated with psychological distress (as measured by HADS-
Anxiety, HADS-Depression).
Althoughsomeresearchershavesuggestedthattimesincedi-
agnosisisassociatedwithincreasedreportsofgrowth,4,20inthis
study growth was not significantly correlated with time since
cancerdiagnosis.Inagreementwithourresults,previousstudies
have found no correlations in breast cancer patients.27
It is worth noting that every patient hasa culture. Cultural as-
pects of values and behaviors are the key variables, along with
life experiences, socio-economic status, and personality differ-
ences that affect the meaning of cancer for both individuals
and their families, as well as how they cope with the disease .29
Thus,itisimportanttomentiontheclosebondsinaGreekfamily,
especially towards coping with cancer.30The family quite often
assumesresponsibilitiesfordecision-makingonthepatient’sbe-
half.29Recent studies indicate that physicians, even when they
inform the patients, usually inform their relatives first.31In an-
other study, only 37% of those interviewed correctly provided
their diagnosis.32Whether this ‘‘lack of information’’ is a prob-
lem of ‘‘tradition/mentality’’ of patients and their families and
how this might affect growth is a question that remains to be
answered.
Table 4
Correlation coefficients between PTGI and HADS
HADS-A HADS-DHADS-T
PTGI-T
PTGI-I
PTGI-II
PTGI-III
PTGI-IV
PTGI-V
0.054
?0.036
?0.095
0.080
0.115
0.193
?0.110
0.009
?0.314*
?0.109
?0.105
0.006
?0.032
?0.015
?0.231
?0.015
0.067
0.111
*p < 0.05, **p < 0.01, ***p < 0.001.
BStd. Error
p Value
Dependent variable: PTGI-II (New Possibilities)
Age
Marital status
Education
Metastasis time
Number of metastasis
Radiotherapy
HADS-Anxiety
HADS-Depression
R2: 31.4%
?2.784
1.617
?0.092
0.429
0.866
1.039
?0.067
?0.315
0.976
0.975
0.652
0.885
0.871
0.928
0.149
0.159
F ¼ 3.668
0.005
0.101
0.888
0.629
0.323
0.266
0.653
0.051
p < 0.001
Dependent variable: PTGI-V (Appreciation of Life)
Age
Marital status
Education
Metastasis time
Number of metastasis
Radiotherapy
HADS-Anxiety
HADS-Depression
R2: 28.4%
?3.592
1.368
?0.448
0.885
?1.123
0.799
0.133
?0.094
0.938
0.937
0.627
0.850
0.838
0.892
0.143
0.153
F ¼ 3.176
0.000
0.148
0.477
0.301
0.184
0.373
0.356
0.542
p ¼ 0.001
Dependent variable: PTGI-Total
Age
Marital status
Education
Metastasis time
Number of metastasis
Radiotherapy
HADS-Anxiety
HADS-Depression
R2: 20.7%
?8.010
10.069
?0.200
?0.196
1.962
2.567
0.061
?0.429
3.773
3.769
2.520
3.420
3.369
3.588
0.576
0.615
F ¼ 2.082
0.037
0.009
0.937
0.954
0.562
0.476
0.916
0.487
p ¼ 0.030
385
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Psychological/emotional well-being is a critical domain
that is included in most efforts to measure overall quality of
life.33The importance of patients’ quality of life is well recog-
nized.34
In an interesting study involving 1500 Greek
physicians assessing whether quality of life is a variable deter-
mining therapeutic choices in cancer care, only 16% of the re-
spondents would choose an intensive care unit for a patient in
the terminal stage, whereas 82% would not.35
In conclusion, patients’ young age and being with a partner
influence the experience of posttraumatic growth in breast can-
cer patients. The end of life offers opportunities for personal
growth and the deepening of relationships. When physical
symptomsandsufferingarecontrolled,itiseasiertoaddresspa-
tients’ central concerns.36From an applied perspective, clini-
cians should be aware of the potential for positive change in
their clients following trauma and adversity. Positive changes
maybeusedasfoundationsforfurthertherapeuticwork,provid-
inghopethatthetraumacanbeovercome.37Facilitationofpost-
traumatic growth is crucial to all caring professions.38Values,
attitudes and behaviors differ greatly across cultures and have
implications on how people cope.39Hence, the importance of
culturally sensitive communication cannot be overstated.
Conflict of interest statement
None declared.
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