Subjects were 49 patients scheduled to receive high-dose chemotherapy and an autologous bone marrow transplant. Consistent with previous coping research ...
Journal of Clinical Psychology in Medical Settings, VoL 3, No. 4, 1996
Coping Strategies and Psychological Distress in Cancer Patients Before Autologous Bone Marrow Transplant Johanna J. Mytko, 1 Sara J. Knight, 1,4 Dania Chastain, 2 Patricia B. Mumby, 3 Amy K. Siston, 3 and Stephanie Williams 3
The increased use of bone marrow transplantation (BMT) to treat a variety of cancers has led researchers to study psychological functioning of BMT patients. The majority of studies conducted, however, has focused on adjustment after transplantation. Cancer patients' use of coping strategies before undergoing this procedure may also relate to levels of psychological distress. Our aims were (1) to provide normative coping data, controlling for situation-specific variables with a homogeneous sample, targeted stressor, and fixed time point, using the Ways of Coping Questionnaire; and (2) to identify coping strategies associated with distress before high-dose chemotherapy. Subjects were 49 patients scheduled to receive high-dose chemotherapy and an autologous bone marrow transplant. Consistent with previous coping research, we found that escape-avoidance was related to psychological distress on several measures. Item endorsement analyses of the escape-avoidance subscale suggest that patients may have used more passive than active avoidance strategies. Subsequent participation in a longitudinal study was not affected by initial levels of avoidant coping. KEY WORDS: bone marrow transplant; high-dose chemotherapy; coping; psychological distress.
1Department of Psychiatry & Behavioral Sciences, Northwestern University, Chicago, Illinois. 2Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville, Virginia. 3Departments of Psychiatry and Medicine, University of Chicago, Chicago, Illinois. 4To whom correspondence should be addressed at Department of Psychiatry and Behavioral Sciences, Northwestern Univeristy, 303 East Ohio, Suite 550, Chicago, Illinois 60611. 355 1068-9583/96/1200-0355509.50/0@ 1996PlenumPublishingCorporation
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INTRODUCTION Bone marrow transplant (BMT), introduced in 1957 (Thomas, Lochte, & Lu, 1957), is now used to treat a variety of life-threatening oncologic and hematologic diseases such as leukemia, lymphoma, sarcoma, melanoma, breast cancer, and other cancers (National Institutes of Health, 1989). Better survival rates, increased number of diseases treated with bone marrow transplantation, and decreased necessity for identical sibling donors contribute to the expanding use of BMT (Andrykowski, 1994). During the 1980s, the number of bone marrow transplants performed increased at the rate of I1 to 15% annually (Bortin & Rimm, 1989). Recently, the Blue Cross and Blue Shield Association Technology Evaluation Center concluded that high-dose chemotherapy with autologous stem cell support is as efficacious in the treatment of metastatic breast cancer as conventional therapy (Blue Cross and Blue Shield Association Technology Evaluation Center, 1996). Due to increased use of bone marrow transplant, researchers have begun to study psychosocial issues related to this treatment. Few studies, however, have focused on autologous bone marrow transplant as opposed to allogeneic transplants. In addition, most researchers have focused on quality-of-life issues and adjustment after completion of the procedure. Little is known about the psychosocial functioning of cancer patients anticipating bone marrow transplantation (Rodrigue, Boggs, Weiner, & Behen, 1993). Patients may experience increased distress as they face an emotionally and physically taxing procedure. The ways patients cope with distress before treatment may account for differences in their subsequent adjustment. Much of the research on coping to date has focused on coping-situation matches to identify efficacious strategies. The literature has moved from studies of the stressful situations in daily living to more extreme stressful events, such as multiple sclerosis and spinal cord injury (Wineman, Durand, & Steiner, 1994), hypertension, diabetes, and arthritis (Felton, Revenson, & Hinrichsen, 1984), recurrent genital herpes (Manne & Sandier, 1984), and cancer (Heim, Augustiny, Schaffner, & Valach, 1993; Hilton, 1989; Burgess, Morris, & Pettingale, 1988; Carver et al., 1993; Felton & Revenson, 1984; Friedman, Baer, Lewy, Lane, & Smith, 1988). Studies of coping in physically ill patients have identified coping strategies that may be less helpful than others in reducing distress. Avoidant coping has been associated with higher levels of psychological distress across varied chronic illnesses (e.g., cancer, hypertension, diabetes, arthritis, dementia) (Bombardier, D'Amico, & Jordan, 1990; Carver et al., 1993; Hilton, 1989; Heim et al., 1993; Felton et al., 1984; Felton & Revenson, 1984;
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Friedman et al., 1988; Manne et al., 1994; Vitaliano, Maiuro, Russo, & Becker, 1987). Folkman and Lazarus (1984) describe escape-avoidance as behavioral or cognitive attempts to ignore the stressful situation. Unfortunately, higher levels of escape-avoidance coping are found in individuals faced with health threats or unchangeable events as compared to individuals in less stressful or changeable circumstances (Folkman, Lazarus, Dunkel-Schetter, De Longis, & Gruen, 1986). The consistency of the association between avoidant coping and distress is striking, given the variability in measurement that exists among coping studies. Coping is currently conceptualized as a dynamic process dependent on changing situations and appraisals (Folkman & Lazarus, 1984). Most researchers have not focused on the situation-specific nature of coping and have not controlled for or specified the timing and target of coping measurement during the cancer experience, the type or stage of cancer studied or the type of cancer treatment. A recent study by Manne et al. (1994) assessed coping in breast cancer patients receiving chemotherapy. This study was the first to measure coping using the Ways of Coping Questionnaire (WCQ; Folkman & Lazarus, 1987) at a specific time during treatment (i.e., the last chemotherapy infusion) and ask subjects to give coping responses based on their experience with chemotherapy, specifically. They found that escape-avoidance coping was related to negative affect and that distancing, positive reappraisal, and selfcontrolling coping were related to positive affect. Although this study dealt with coping related to chemotherapy, little is known about whether particular coping strategies may be helpful or deleterious in managing the stress before beginning chemotherapy. One study has reported coping strategies in patients before bone marrow transplant (Rodrigue et al., 1993). Interestingly, they found that a passive form of coping, acceptance-resignation (not avoidance), was related to higher levels of distress. This study, however, did not use the WCQ which is frequently used in medical populations. By assessing WCQ coping strategies used before high-dose chemotherapy and autologous bone marrow transplant, the current study provides normative information about strategies used in this population and situation, which strategies are associated with initial levels of psychological distress, and whether an initial coping strategy (i.e., escape-avoidance) is related to subsequent behavior. Our study expands upon the Rodrigue et al. (1993) results and contribute to the understanding of coping and psychological factors associated with autologous BMT. Baseline data on coping strategies may be used to improve efforts to support patients psychologically, before and during chemotherapy.
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METHOD Sample and Procedure
The sample consisted of 49 patients planning to undergo high-dose chemotherapy and autologous bone marrow transplant for a variety of previously diagnosed cancers. All patients received dose-intensive chemotherapies. Toxicities and length of hospitalization were expected to be equivalent across all protocols. Chemotherapy protocols included thiotepa and cytoxan; cisplatin, carmustine, and cytoxan; carboplatin and ifosfamide; carboplatin and etoposide; and cytoxan, cytosine, arabinoside, and busulfan. The sample consisted mainly of middle-aged (M = 41.8; range, 21-57), married (71.4%), white (85.7%) females (88%). The majority of patients had diagnoses of breast cancer (71.4%), had received prior treatment (89.8%), and had advanced stage cancers (Stage IV = 61.2%). Table I further describes the sample's demographic and medical characteristics. All participants completed baseline measures immediately after the consent procedure within the 2 weeks prior to their hospitalization. InTable I. Demographic and Medical Characteristics
Characteristics Age (yr) Mean Range Sex (%) Male Female Ethnic status (%) White African American Hispanic Other Diagnosis (%) Breast Lymphoma & Hodgkin's Other Stage (%) II III IV Other Prior cancer treatment (%) Other chronic illness (%)
41.8 21-57 12 88 85.7 6.1 2.0 2.0 71.4 14.3 14.3 14.3 t2.2 61.2 12.3 89.9 34.7
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formed consent was obtained after provision of detailed explanation of the study and its potential risks and benefits. There were no differences in consent procedures across diseases, stages of disease, and chemotherapy protocols. The informed consent form in Year 2 incorporated information about a psychological intervention that participants received that year. There were no other differences in consent procedure between the 2 years. Measures
All of the following measures have been used previously in psychooncology studies and were selected to assess a wide range of emotional and functional symptoms.
Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The BDI is a 21-item measure used to assess the presence and severity of depressive symptomatology. The BDI is comprised of 13 cognitive-affective and 8 somatic symptoms items, yielding a range of possible scores from 0 to 63. A score of 10 usually signifies a mild depression. High internal consistencies (.88-.91) have been reported for the measure (Beck & Steer, 1989; Welch, Hall, & Walkey, 1990).
Spielberger State-Trait Anxiety Inventory (STAI; Spielberger, 1963). The STAI is a brief (40-item) self-report measure used to assess anxiety, both generally (trait) and situationally (state). High internal consistencies (.88.92) have been reported for each subscale (Ramanaiah, Franzen, & Schill, 1983).
Profile of Mood States (POMS; McNair, Lorr, & Droppelman, 1971). The POMS is a brief self-report measure consisting of six scales (Tension, Anger, Depression, Concentration, Vigor, and Fatigue), which have been used frequently to assess mood states in cancer patients. A score for total mood disturbance (TMD) was derived by adding the raw score for the least somatically related subscales (Tension, Anger, Confusion, and Depression). This TMD score is frequently used with medical patients to eliminate somatic symptoms which may relate to disease and/or treatment rather than psychological distress. Symptom-Checklist-90 (SCL-90: Derogatis, 1983). This 90-item measure with nine subscales assesses psychological and physical symptom patterns. To measure global distress, a General Symptomatic Index score (GSI) was derived by adding the raw scores for each subscale.
Ways of Coping Questionnaire--Revised (WCQ; Folkman & Lazarus, 1987). The WCQ was used to assess the cognitive and behavioral efforts people use when faced with a taxing situation. A raw score (total points endorsed on each subscale), an average score (the average number of items
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endorsed on each subscale), or a relative score (contribution of each subscale relative to the others) can be used to assess either the "use of" or the "reliance on" a coping strategy. Items are rated on a 4-point Likert scale. For the current study, instructions for the scale were modified to be more specific to the problem of the cancer experience and upcoming treatment. Subscales include confrontative coping, distancing, serf-controlling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving, and positive reappraisal. Moderate internal consistencies (.61-.81) have been reported for WCQ subscales (Folkman & l.xtzarus, 1987; Folkman, Lazarus, Gruen, & DeLongis, 1986).
RESULTS
The means and standard deviations for the WCQ are listed in Table II and include the three types of possible scores (raw, average, and relative). Except for a slightly lower raw score on the escape-avoidance and positive reappraisal subscales, the means were similar to those of a sample of patients receiving chemotherapy reported by Manne et aL (1994). We found higher means on the distancing, self-controUing, seeking social support, escape-avoidance and positive reappraisal subscales than in a sample of nonmedical patients reported by Folkman, Lazarus, Dunkel-Schetter, DeLongis, and Gruen (1986). Internal consistency reliabilities for the eight WCQ subscales as estimated by Cronbach's alpha are also provided in Table II. Except for the lower reliabilities on self-control and accepting responsibility, the internal consistencies were similar to those from a sample of breast cancer patients reported by Manne et aL (1994). Our reliabilities were also similar to those
Table
If. Means, Standard Deviations, and Internal Consistenciesof Ways of Coping Subscales Score [M (SD)] Internal Average Relative Raw consistency
Confrontative coping Distancing Serf-controlling Seeking social support Accepting responsibility Escape-avoidance Planful problem solving Positive reappraisal
.70 1.05 1.01 1.I9 .48 .67 1.15 .98
(.44) (.55)
(.52) (.66) (.50) (.52) (.51) (.72)
.09 .15 .13 .17 .06 .09 .16 .12
(.06) (.09) (.05) (.08) (.05) (.07) (.07) (.07)
4.19 6.33 7.12 7.14 1.93 5.36 6.95 6.86
(2.62) (3.28) (3.68) (3.98) (1.99) (4.19) (3.10) (5.04)
.49 .64 .60 .70 .48 .75 .57 .84
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from a sample of nonmedical patients (Folkman, Lazarus, Gruen, & DeLongis, 1986), except for slightly lower reliabilities on confrontative coping and accepting responsibility. The internal consistency reliabilities for several WCQ subscales in our study were low (
