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Biological Research For Nursing
http://brn.sagepub.com/content/9/3/205
The online version of this article can be found at:
DOI: 10.1177/1099800407309374
2008 9: 205Biol Res Nurs
Yang and Julie Djeu
Cecile A. Lengacher, Mary P. Bennett, Lois Gonzalez, Danielle Gilvary, Charles E. Cox, Alan Cantor, Paul B. Jacobsen, Chiu
Immune Responses to Guided Imagery During Breast Cancer Treatment
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Immune Responses to Guided Imagery
During Breast Cancer Treatment
Cecile A. Lengacher, RN, PhD, Mary P. Bennett, PhD, RN, ARNP,
Lois Gonzalez, PhD, ARNP, Danielle Gilvary, BS, Charles E. Cox, MD,
Alan Cantor, PhD, Paul B. Jacobsen, PhD, Chiu Yang, RN, MSN,
and Julie Djeu, PhD
Women, who are the most frequent users of com-
plementary alternative medicine (CAM), tend to seek
alternatives to help them cope with cancer diagnoses.
Lengacher and colleagues (2003) estimated that 64%
to 86% of women with breast cancer used CAM. Of
these women, 43% used relaxation techniques alone
at least once and 16% used them on a regular basis.
In addition, 27% used guided imagery at least once
with 6% using it regularly. Schmidt and Ernst (2004)
identified guided imagery as one of the most fre-
quently used CAM cancer therapies.
Psychological interventions and behavioral pro-
grams such as guided imagery and relaxation have
been shown to be effective in helping patients cope
with the stress of cancer. Although researchers have
studied the use of guided imagery in cancer patients,
W
orld cancer rates are expected to double by
2020. It is predicted that the number of per-
sons living with cancer will increase from 1.6
to 2.3 million from 2000 to 2050 (Simmonds, 2003). In
2006, an estimated 214,640 women in the United
States will be newly diagnosed with breast cancer, and
40,970 will die from the disease (Jemal et al., 2006).
Background: The use of relaxation and guided
imagery to reduce stress and improve immune func-
tion has great potential benefits for patients with
breast cancer. Methods: This pilot study used a
pretest–posttest experimental design with 28 breast
cancer patients, aged 25 to 75 years, with the diag-
nosis of stage 0, 1, or 2 breast cancer. The experi-
mental group received a relaxation and guided
imagery intervention and the control group received
standard care. The effects of the intervention on
immune function were measured by natural killer
(NK) cell cytotoxicity and IL-2–activated NK cell
activity prior to surgery and 4 weeks postsurgery. NK
cell activity was measured using a 15-hr incubation
chromium release assay. Cytotoxicity of NK cells
was measured against chromium-labeled K-562 tar-
get cells. IL-2 was used to enhance reactivity of NK
cells against tumor cells. After incubation for 15 hr,
cytotoxicity was measured through the release of
radioactive chromium. Results: Significant differences
between groups were found at 4 weeks postsurgery. T-
tests showed increased NK cell cytotoxicity for the inter-
vention group at 100:1, 50:1, and 25:1 effector cell:
target cell ratios (E:T) (p < .01 to p < .05) and increased
activation for IL-2 at 100:1, 50:1, 25:1, and 12.5:1 (E:T)
(p < .01 to p < .05) for the intervention group as com-
pared to the control group. Discussion: These findings
suggest that a relaxation intervention such as guided
imagery could have an effect on NK cell cytotoxicity
and NK cell cytotoxicity after activation with IL-2 in
patients undergoing surgery for breast cancer.
Keywords: guided imagery; immune response; breast
cancer; natural killer cells
From University of South Florida College of Nursing (CAL,
LG); Western Kentucky University School of Nursing
(MPB); H. Lee Moffitt Cancer Center, University of
South Florida (DG, CEC, AC, PBJ, JD); National Taiwan
University (CY).
Address correspondence to: Cecile A. Lengacher, University
of South Florida College of Nursing, 12901 Bruce B. Downs
Blvd, MDC 22, Tampa, FL 33612-4766; e-mail: clengach@
health.usf.edu.
Biological Research Nursing
Volume 9 Number 3
January 2008 205-214
© 2008 Sage Publications
10.1177/1099800407309374
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205
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few researchers have examined the effects of relax-
ation and guided imagery in randomized clinical tri-
als (Baider, Peretz, Hadani, & Koch, 2001; Burish,
Snyder, & Jenkins, 1991; Lyles, Burish, Krozely, &
Oldham, 1982; Syrjala, Donaldson, Davis, Kippes, &
Carr, 1995). Moreover, only a few studies have
examined the effects of relaxation and guided
imagery on the immune system in breast cancer
patients. Of these, only two were designed as ran-
domized clinical trials (Richardson et al., 1997; Yan,
Xinfan, Jigang, Hardy, & Mountainbear, 2001). In
addition, four nonrandomized studies examined the
effects of guided imagery without relaxation on
breast cancer patients’ immune systems (Bakke,
Purtzer, & Newton, 2002; Gruber et al., 1993;
Richardson et al., 1997; Schedlowski, Jung,
Schimanski, Tewes, & Schmoll, 1994).
Findings of these studies suggest that relaxation
and guided imagery, as self-regulating activities, can
influence the immune system by calming the corti-
cal and limbic regions of the brain (Bakke et al.,
2002; Richardson et al., 1997). The underlying
mechanism of action resides in the psychoneuroim-
mune network, a complex system of cells that inter-
act using extensive subcellular and molecular level
communication. This communication flows bidirec-
tionally among the neuroendocrine, nervous, and
immune systems (Booth, 1990; Glaser & Kiecolt-
Glaser, 2005).
Thus, in addition to alleviating feelings of anxi-
ety, it is possible that techniques such as relaxation
and guided imagery can improve the immune sys-
tem’s ability to fight cancer (Richardson et al.,
1997). Research has documented a relationship
between stress and changes in the immune system
(Andersen, Kiecolt-Glaser, & Glaser, 1994; Herbert
& Cohen, 1993; Kiecolt-Glaser, McGuire, Robles, &
Glaser, 2002; Kiecolt-Glaser, Robles, Heffner,
Loving, & Glaser, 2002; Mills & Dimsdale, 1996;
Morley, Benton, & Solomon, 1991). Stress-reducing
activities such as relaxation therapies may reduce
the effect of stress on glucocorticoids, which act as
immunomodulators (Reichlin, 1994; Spiegel &
Sephton, 2001). Various stressors act to downregu-
late the immune system, primarily through the
mechanism of elevated levels of cortisol, a glucocor-
ticoid. Cortisol is immunosuppressive and acts to
reduce the numbers and function of leucocytes as
well as to suppress natural killer (NK) cell activity
(Rabin, Cohen, Ganguli, Lysle, & Cunnick, 1989;
Whiteside, 2006; Zeller, McCain, & Swanson,
1996). Suppression of NK cell activity leads to a
decreased ability to resist illness, as NK cells play a
role in defense against many disease processes and
illnesses. However, suppression of NK cell activity
can be particularly damaging for persons with can-
cer, since NK cells have the ability to kill both virally
infected cells and tumor cells while sparing normal
cells (Kiecolt-Glaser, Robles, et al., 2002; Whiteside
& Herberman, 1995).
Decreased NK cell activity may, in fact, be an
important factor in the development of cancer (Adler,
Chervenick, Whiteside, Lotzova, & Herberman, 1988).
Low NK cell activity has been found in members of
cancer families as compared to age-matched individ-
uals without cancer (Bovbjerg & Valdimarsdottir,
1993; Shevde, Joshi, Shinde, & Nadkarni, 1998),
thus suggesting that unaffected family members may
be at higher risk for cancer. Recent evidence in ani-
mal models indicates that stress both decreases NK
cell activity and enhances metastasis of transplantable
tumors (Stefanski, 2001). NK cell activity may also
have some value in predicting recurrence, metastasis, and
decreased survival (Herberman, 1991; Levy, Herberman,
Maluish, Schlien, & Littman, 1985; Maes et al., 1998;
Whiteside, 2006; Whiteside & Herberman, 1995).
In addition to changing levels of glucocorticoids,
there are other ways of increasing or decreasing the
immune system response to pathogens and tumor
cells. Reichlin (1994) established the existence of a
link between the immune and neuroendocrine sys-
tems in the activation of immunocompetent cells,
which trigger cytokine release. These cytokines can
upregulate or downregulate the immune system’s
response to cellular invaders such as tumor cells.
Evidence indicates that immune competence and
cytokine activation are part of the normal process of
cancer prevention at the cellular level (Whiteside,
2006). This normal process may be hindered by
stress and the subsequent immunoresponse to stress
(Andersen et al., 1994). Cytokines have been reported
to play a key role in lymphocyte survival (Schluns &
Lefrancois, 2003). The cytokine interleukin-2 (IL-2)
has the most documented ability to enhance antitu-
mor activity (Van Parijs et al., 1999). A variety of
cytokines, particularly IL-2, are capable of modulat-
ing NK cells and act as potent stimulators of NK
cell cytotoxic function (Lanier, Benike, Phillips, &
Engleman, 1985; Trinchieri et al., 1984). IL-2
increases the cytotoxic capacity of NK cells by
increasing the expression of genes for the cytolytic
factors perforin and granzyme (DeBlaker-Hohe,
Yamauchi, Yu, Horvath-Arcidiacono, & Bloom,
1995; Lotzova, 1993; Salcedo, Azzoni, Wolf, &
206 Biological Research for Nursing/ Vol. 9, No. 3, January 2008
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Perussia, 1993). Therefore, alterations in NK cell
cytotoxic function are regulated by changes in key
cytokines, and the effects of stress on these
cytokines ultimately leads to the changes in NK cell
functioning seen in stressed persons. Thus, it is the-
oretically possible that decreasing the effects of
stressors on cytokines will improve NK cell activity
and ultimately improve patients’ ability to resist the
progression of disease processes such as cancer.
Few clinical intervention studies have been con-
ducted to directly document the role of stress in the
development and progression of cancer. For instance,
it is highly unusual to have baseline stress and
immune measures on people prior to the diagnosis
of cancer, as most practitioners and diagnostic labo-
ratories do not include these measures in a standard
exam. Many of the measures used to document the
effects of stress on immune function and on the rel-
ative ability of a person’s immune cells to destroy
tumor cells are not readily available to practitioners
in a clinical setting. Therefore most people have
never had any type of cytotoxicity measure recorded
prior to being diagnosed with cancer. Furthermore,
recent research assessing the cytoxicity of NK cells
has been conducted primarily in animals and per-
sons who have never been diagnosed with cancer.
There have been several models designed to
determine how the immune system and tumor cells
interact in both humans and animals. Studies have
shown that decreased NK cell cytotoxicity is related
to increased metastasis (Levy, Herberman, Lippman,
& d’Angelo, 1987; Rakhmilevich, Janssen, Hao,
Sondel, & Yang, 2000). White, Jones, Cooke, and
Kirkham (1982) reported that women diagnosed
with breast cancer have significantly reduced NK
cell cytotoxicity (destruction of tumor cells). Also
there is a significant correlation between depressed
NK cell cytotoxicity and lymph node involvement in
women with primary breast cancer (Levy et al.,
1985). In contrast, increased NK cell activity leads
to cancer regression (Whiteside & Herberman,
1995), a finding that has significance for treatments
such as relaxation and guided imagery, which may
act to reduce the effects of stress and improve NK
cell functioning in cancer patients.
The purpose of the current study was to deter-
mine if relaxation and guided imagery had positive
effects on immunological functioning in early-stage
breast cancer patients. The premise for the study
was that there is a relationship among stress, cancer,
and immune activity; therefore, stress-reducing
interventions that have the potential to improve
immune activity also have the potential to improve
patients’ abilities to resist the actual disease process.
The use of relaxation and guided imagery in this
study relied on two assumptions:
• Stress can affect the functioning of the immune
system, particularly NK cell cytotoxicity.
• The progression of cancer is related to the reduc-
tion of immune surveillance by NK cells, known
to remove cancer cells (Bakke et al., 2002).
Methods
Sample and Design
This study was approved by the scientific review commit-
tee of the H. Lee Moffitt Cancer and Research Institute
and the University of South Florida Institutional Review
Board. Women who were diagnosed with early-stage
breast cancer but had not yet undergone surgery were
recruited from the breast cancer clinics at H. Lee
Moffitt Cancer Center and NCI Research Institute in
Tampa, Florida. Inclusion criteria included a diagno-
sis of early-stage breast cancer and the ability to read
and speak English.
An experimental randomized pretest–posttest
design was used to determine if there were differ-
ences in NK cell activity between women randomly
assigned to the control group receiving standard
care and those assigned to the intervention group.
Procedure
Participants were enrolled during the clinic visit at
which they received their diagnosis, which was approx-
imately 2 to 3 weeks prior to surgery. Demographic
data were collected using a clinical history form,
which provided information on sociodemographics,
clinical history, and health-related behaviors such as
smoking, exercise, and caffeine and alcohol con-
sumption. Samples for the immunological assays, 30
ml of whole blood, were obtained at this time (base-
line) and 4 weeks postsurgery. To avoid possible vari-
ations because of differences in diurnal patterns, the
blood samples were collected at the same time in the
morning. Participants were randomly assigned to
either the control group or the experimental group.
Participants in both groups were invited to participate
in standard care planned for all patients through the
H. Lee Moffitt Cancer and Research Institute. In
addition, participants in the intervention group were
scheduled for a relaxation session as described below.
Participants in the control group received standard
Immune Responses to Guided Imagery / Lengacher et al. 207
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care and at the end of the intervention could receive the
relaxation tapes if they so desired. After 4 weeks, immuno-
logical data and clinical history data were obtained.
Intervention
Participants in the intervention each met once for a
30-min relaxation and guided imagery session with a
therapist trained in relaxation guided imagery and also
received guided imagery tapes. They were asked to lis-
ten to the tapes a minimum of 3 times per week. In the
session, the therapist taught participants passive pro-
gressive relaxation to prepare them for guided imagery.
Training focused on concentration and visualization of
the immune cells destroying their cancer cells. This
method was originally described by Simonton,
Matthews-Simonton, and Creighton (1978) and has
been used in other studies (Bakke et al., 2002).
Prior to each relaxation session, the therapist–
nurse spent a few minutes talking with each patient
about how she was feeling physically and gave her
basic information on the immune system’s role in
combating cancer. The relaxation session began with
passive progressive relaxation, during which the thera-
pist suggested that patients relax a series of muscle
groups and body parts. The therapist explained that
passive progressive relaxation highlights deep breath-
ing techniques combined with imagery to create deep
relaxation and naturally calms the body and the mind,
preparing them for guided imagery. Patients were
encouraged to say a word silently to themselves, such
as relax, as they exhaled and mentally scanned the
muscle group for any further tension. Next, the thera-
pist asked patients to allow that tension to leave the
body and facilitated deeper relaxation by providing
imagery. Focused breathing was also incorporated into
the session (Berenson, 1988). Patients then moved into
guided imagery focused on health-promoting images. If
participants indicated they were having difficulty, the
therapist suggested soothing images. The women were
encouraged to use the audiotapes to practice at home
a minimum of 3 times per week and to document home
sessions in a daily diary.
Immune Parameters
The immune measures used in this study were NK cell
function and cytokine IL-2–enhanced NK cells (also
known as lymphokine activated killer cells or LAK).
These measures were selected as the most reliable and
most likely to demonstrate a change over time, based
on published studies of the susceptibility of NK cells
to psychoneural changes and the hypothesis that
NK-cell function may be modulated by behavioral
manipulation. These measures also allowed us to inves-
tigate the ability of IL-2 to activate NK cells, thus
demonstrating whether cellular products such as
cytokines also respond to the psychological intervention.
Preparation of Human Peripheral
Blood Mononuclear Cells (PBMC)
Prior to surgery and 4 weeks after surgery we obtained
30 ml of heparinized whole blood from each study
participant. Samples were diluted 1:2 in phosphate
buffer solution (PBS) and layered on 12 ml of Ficoll-
Hypaque solution (Gamero, Ussery, Reintgen, Puleo,
& Djeu, 1995). After centrifugation at 400g for 20
min at room temperature, the interface band of
PBMC was collected and washed twice with PBS.
The contaminating red blood cells were removed
from PBMC by hypotonic shock with sterile distilled
water for 30 s (Palma, Cassone, Serbousek, Pearson,
& Djeu, 1992). The PBMC were then resuspended in
RPMI-1640 medium containing 5% heat-inactivated
human AB serum (Biocell Laboratories, Carson, CA),
2 mM L-glutamine, 10 U/ml penicillin, 100 µg strep-
tomycin, and 5 mM/L HEPES buffer (GIBCO). All
media and reagents contained less than 0.1 ng/ml of
endotoxin, as determined by the Limulus Amoebocyte
Lysate assay (M. A. Biologics, Walkersville, MD), to
avoid nonspecific activation of the PBMC.
Measurement of Cytotoxicity
A 15-h chromium (
51
Cr) release assay was used to
measure the cytotoxicity of PBMC against K562
tumor cell targets (Nenlife Sciences; Rossi, Pericle,
Rashleigh, Janiec, & Djeu, 1994). Briefly, 96-well
rounded-bottom microliter plates were set up in trip-
licate wells with 100 ul of PBMC at various concen-
trations to achieve effector cell:target cell (E:T) ratios
of 100:1, 50:1, 25:1, and 12.5:1. Recombinant
human IL-2, 1000 units/ml, was added to PBMC.
The cells were then incubated at 37°C in 5% CO
2
for
2 hr. K562, an erythroleukemia NK sensitive tumor
cell line, was labeled with 100 µCi of Na
2
51
CrO
4
(Amersham, Arlington Heights, IL) for 1 hr at 37°C.
The cells were washed twice with PBS and 100 µl
were added to effector cells at 5 × 103 cells/well. After
a 15-hr incubation at 37°C, 100 µl of supernatant was
collected, and radioactivity of the
51
Cr released from
target cells was measured by a gamma counter. Samples
were collected in triplicate wells, and the mean value
was determined for each sample dilution: that is, 100:1,
208 Biological Research for Nursing/ Vol. 9, No. 3, January 2008
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50:1, 25:1, and 12.5:1. The statistical program cor-
rected for outliers in the sample. The percentage of
specific lysis was calculated by the formula [Experimental
cpm-spontaneous release cpm/maximal release cpm
incorporated] x 100.
Antitumor activity may depend on concurrent
stimulation of T cells and macrophages that produce
cytokines, such as IL-2, which subsequently
increase the activity of other immune system com-
ponents. The tumoricidal activity of NK cells is
increased by cytokines. These activated NK cells are
also known as LAK cells and may respond differently
than NK cells to a similar stimulus. In this study, we
did not isolate NK cells from the PBMC population.
Instead, we used IL-2 to target activation of the NK
cells. LAK cells within the PBMC population were
produced by exposing some of the patients’ NK cells to
IL-2 during the 15-hr incubation period. Cytotoxicity
was then measured through the release of radioac-
tive chromium into the supernatant. Percentage
lysis was calculated at the 100:1, 50:1, 25:1, and
12.5:1 E:T ratios.
Statistical Analysis
Means generated from the independent groups—
relaxation and guided imagery compared to standard
care—were analyzed using pooled Student t tests.
Comparisons of differences within groups were made
with two-sided, paired t tests. ANCOVA was used to
determine if the two groups varied in immune func-
tion, adjusted for the covariates of age, stage of dis-
ease, and type of surgery. All statistical analyses were
conducted using SPSS statistical software.
Results
Participants
We recruited 32 participants who met the inclusion
criteria, and 28 completed both pre- and poststudy
blood draws for the immunological assays, resulting
in an 88% completion rate. Through random assign-
ment, 13 were placed in the control group receiving
standard care, and 15 were placed in the guided
imagery group. Demographic and clinical character-
istics of the participants are provided in Table 1. The
majority (53%) were married, and a large percentage
(35.7%) were divorced. Although other ongoing
treatments for cancer could affect immune function,
we controlled for this possibility by ensuring that
there were no changes in these treatments during
the pretest to 4 weeks postsurgery study period,
which is the time period during which other medical
treatment for breast cancer usually begins. The
groups did not differ significantly on stage
of disease or type of surgery at baseline using
chi square analysis.
Imagery Practice
Women in the guided imagery group were asked to
listen to the tapes a minimum of 3 times per week.
All 15 women used the tapes to practice the guided
imagery; however, the amount of practice varied
from 0 to 16 times per week. Only 2 women
reported not practicing at all for 4 weeks. The over-
all mean number of practice sessions per week was
4.9, with the average number of weekly sessions for
each woman ranging from 2.3 to 13.6.
Immunological Studies
This study evaluated the functional NK cell cytotox-
icity measured by % lysis and LAK activity at four dif-
ferent E:T ratios. Data collected prior to surgery were
compared to data collected 4 weeks after surgery for
participants in both the intervention group and the
control group. As expected, at pretest there were no
significant between-group differences in NK cell
cytotoxicity (p > .05) or in LAK activity, indicating
that the random group assignment was reasonably
effective in controlling for possible differences in
baseline immune function (see Table 2).
At the 4-week posttest data-collection point,
two-tailed independent t tests indicated that func-
tional NK cell cytotoxicity (measured in % lysis) dif-
fered significantly between the intervention group
and the control group at E:T ratios of 100:1, 50:1,
and 25:1 (t tests, p < .01 to p < .05; Figure 1 and
Table 3). Also there were significant differences in
cytotoxicity from the IL-2–enhanced LAK cells for
participants between the two groups at E:T ratios of
100:1, 50:1, 25:1, and 12.5:1 (p < .01 to p < .05), as
shown in Figure 2. These results indicate that NK
cells from participants in the intervention group
were better able to respond to IL-2 stimulation than
NK cells from participants in the control group.
Functional cytotoxicity increased significantly for
women in the intervention group from pre- to
posttest (Figure 3). Although LAK activity decreased
for participants in both groups, most likely because
of the stress of surgery, it decreased significantly less
for those in the intervention group (Figure 4). This
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result indicates that the intervention was able to
buffer or mediate the effects of this stress on LAK
function. Analysis of covariance revealed no signifi-
cant differences in immune status between groups
due to covariates of age, stage of disease, or type of
surgery (p = .98 to p = .34).
Discussion
This study tested the immunological effects of a 4-
week guided imagery program in 28 women with
stage 0, 1, or 2 breast cancer. The results show that
short-term relaxation and guided imagery had bene-
ficial immunological effects on NK cell cytotoxicity
and IL-2 activation of NK cells, or LAK activity, after
4 weeks of participation.
These findings support the earlier work of Gruber
and colleagues (1993) and Bakke, Purtzer, and
Newton (2002). Gruber’s group found that relaxation,
guided imagery, and biofeedback training were able to
increase NK cell activity in their sample. Bakke and
colleagues did not find significant increases in NK
210 Biological Research for Nursing/ Vol. 9, No. 3, January 2008
Table 1. Demographic and Clinical Characteristics of Study Population (N = 28)
Combined Experimental Group Control Group
Characteristic (N = 28) (n = 15) (n = 13)
Age (mean years) 52.6 48.3 57.6
Working status
Not working 10 (35.7) 6 (40.0) 4 (30.8)
Working full time 14 (50.0) 7 (46.7) 7 (53.9)
Working part time 3 (10.7) 1 (6.7) 2 (15.4)
Other 1 (3.6) 1 (6.7) 0
Level of education
High school diploma 8 (28.6) 1 (6.7) 7 (53.9)
Some college 15 (53.6) 10 (66.7) 5 (38.5)
Graduate education 5 (17.9) 4 (26.7) 1 (7.7)
Marriage
Married 15 (53.6) 8 (53.3) 7 (53.9)
Not married category 13 (46.4) 7 (46.7) 6 (46.2)
Ethnicity
Caucasian 26 (92.9) 14 (93.3) 12 (92.3)
Other 2 (7.1) 1 (6.7) 1 (7.7)
Cancer stage
0 7 (25.0) 5 (33.3) 2 (15.4)
1 16 (57.1) 7 (46.7) 9 (69.2)
2 5 (17.9) 3 (20.0) 2 (15.4)
Surgery type
Mastectomy 12 (42.9) 7 (53.9) 5 (33.3)
Lumpectomy 16 (57.1) 8 (53.3) 8 (61.5)
NOTE: Data are presented as n (%) unless otherwise noted.
Table 2. Independent t-test Comparison of Pretest NK Cell and IL-2 (LAK) Cytotoxicity
Control Group Intervention Group
(n = 13) (n = 15)
E:T Ratio Mean (SD) Mean (SD) Tp
NK 100:1 28.2 (14.2) 29.5 (12.1) –.27 .788
NK 50:1 18.7 (10.0) 23.1 (12.4) –1.01 .326
NK 25:1 11.8 (6.6) 15.2 (10.1) –1.04 .307
NK 12.5:1 7.0 (6.1) 9.4 (7.5) –.89 .378
IL-2 100:1 31.5 (12.6) 37.3 (13.5) –1.15 .259
IL-2 50:1 22.9 (9.6) 30.0 (12.5) –1.65 .109
IL-2 25:1 16.0 (8.6) 20.5 (9.0) –1.36 .185
IL-2 12.5:1 10.6 (5.4) 15.2 (8.6) –1.64 .111
NOTE: LAK = lymphokine activated killer cells; E:T ratio = the ratio of effector cell to target cell. Target cells were K562 tumor cells.
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Immune Responses to Guided Imagery / Lengacher et al. 211
0
10
20
30
40
50
100:1 50:1 25:1
tio
12.5:1
E:T Ra
Control
Relaxation
p = .001
p = .001
p = .001 p = .017
% Lysis
Postintervention IL-2 (LAK)
Figure 2. Between-group comparison of lymphokine-
activated killer cell (LAK) activity (IL-2–stimulated NK cells) at
4 weeks posttest.
-10
-8
-6
-4
-2
0
2
4
6
100:1 50:1 25:1 12.5:1
ET Ratio
% Lysis
Control
Relaxation
Pre- and Posttest Data—NK,
51
Cr Difference
Figure 3. Changes from baseline measures in NK cell cyto-
toxicity by group. NK cytotoxicity decreased in the control group
while remaining stable or improving in the intervention group.
-12
-10
-8
-6
-4
-2
0
2
100:1 50:1 25:1 12.5:1
ET Ratio
% Lysis
Control
Relaxation
Pre- and Posttest Data—IL2 Difference
Figure 4. Changes from baseline in lymphokine-activated killer
cell (LAK) cytotoxicity by group. LAK activity decreased in both
groups but demonstrated less decrease in the intervention group.
Table 3. Independent t-test Comparison of Posttest NK Cell and IL-2 (LAK) Cytotoxicity
Control Group Intervention Group
(n = 13) (n = 15)
E:T Ratio Mean (SD) Mean (SD) Tp
NK 100:1 20.3 (9.7) 33.7 (11.3) –3.33 .003
NK 50:1 15.4 (7.7) 25.7 (10.6) –2.88 .008
NK 25:1 10.9 (6.5) 17.7 (8.4) –2.37 .025
NK 12.5:1 6.5 (5.6) 10.1 (6.9) –1.44 .160
IL-2 100:1 21.6 (12.2) 38.2 (12.1) –3.59 .001
IL-2 50:1 14.8 (9.7) 29.5 (10.5) –3.82 .001
IL-2 25:1 9.0 (6.9) 19.7 (7.7) –3.74 .001
IL-2 12.5:1 6.8 (5.7) 12.7 (6.3) –2.55 .017
NOTE: LAK = lymphokine activated killer cells; E:T ratio = the ratio of effector cell to target cell. Target cells were K562 tumor cells.
a
0
5
10
15
20
25
30
35
40
100:1 50:1 25:1
tio
12.5:1
E:T R
% Lysis
Control Relaxation
p = .160p = .025p = .008p = .003
Postintervention NK,
51
Cr Cytotoxicity
Figure 1. Between-group comparison of NK cytotoxicity
(measured in % lysis) at 4 weeks posttest.
at UNIV OF SOUTH FLORIDA on February 8, 2013brn.sagepub.comDownloaded from
cell activity but instead reported increased numbers
of NK cells in persons treated with relaxation ther-
apy. Because the current study did not include raw
counts of NK cells, it cannot be determined if relax-
ation increased actual numbers of cells or just
increased the cancer-killing abilities of the NK cells
already present.
However, not all studies in this area have had sim-
ilar results. Richardson and colleagues (1997)
reported an increase in interferon gamma in persons
in the imagery/relaxation group with no accompany-
ing increase in NK cell cytotoxicity and a paradoxical
decrease in neopterin, a substance that is normally
increased when macrophages are stimulated with
interferon gamma. Given that two out of the three
findings in this study were contrary to what would
normally be predicted, it is difficult to say how these
findings fit into the current models of immune system
function. In a similar study, Larson and colleagues
(2000) reported no changes in NK cell activity after a
two-session guided imagery intervention in presurgi-
cal breast cancer patients despite the fact that inter-
feron gamma decreased significantly in the control
group but remained stable in the intervention group.
Again, this result is somewhat contrary to current the-
ory concerning the actions of interferon gamma on
NK cell activity, but it may be that two sessions were
insufficient to create a measurable change.
The immune effects of relaxation and guided
imagery may be explained by the release of potent fac-
tors such as neuropeptides and cytokines that can mod-
ulate the immune response (Ben-Eliyahu, Shakhar,
Page, Stefanski, & Shakhar, 2000). In the current sam-
ple of patients, NK cell cytotoxicity was enhanced in the
intervention group, and LAK activity showed resilience
to stress-induced immunosuppression. According to the
current understanding of the actions of IL-2 and other
cytokines such as interferon gamma, these cytokines
act to stimulate and enhance NK cell cytotoxicity, turn-
ing regular NK cells into LAK cells. IL-2 enhancement
occurs because IL-2 is an 18-kDa protein capable of
increasing cytotoxic function through induction of the
expression of genes for cytolitic factors perforin and
granzyme (DeBlaker-Hohe et al., 1995; Lotzova,
1993). This ability may be one of the underlying
mechanisms for the significant increase in NK cell
activity and stablility of LAK activity demonstrated in
the relaxation group.
Questions have arisen concerning the detection of
changes in immune responses when a participant is
already in a stressed condition, because this stress may
lead to low NK cell activity prior to any intervention and
may interfere with the actions of the intervention on
immune function (Schulz & Schulz, 1992). For women
in this study, stress-related immunosuppression may
have been a factor in all of the women because of their
recent cancer diagnoses. However, randomization ade-
quately controlled for this potential, as demonstrated by
the fact that there were no significant between-group
differences in NK cell functioning at baseline. In addi-
tion, the possible confounding factor of differing reac-
tions to the stress of chemotherapy was avoided by
conducting the intervention and posttest sampling prior
to the patients’ chemotherapy treatment phase.
In conclusion, this study supports the hypothesis
that a presurgical relaxation and guided imagery inter-
vention can improve immune function in women
undergoing surgical treatment for breast cancer. This
study also contributes to the growing body of literature
concerning the mechanisms by which stress reduction
techniques may enhance immune function and sup-
ports the use of relaxation and guided imagery in
breast cancer patients as a complementary therapy.
Acknowledgement
This study was funded by the American Cancer Society,
Florida Division.
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