Do Anxiety, Body Image, Social Support and Coping

Strategies Predict Survival in Breast Cancer?

A Ten-Year Follow-Up Study

FLORENCE COUSSON-GÉLIE, PH.D., MARILOU BRUCHON-SCHWEITZER, PH.D.

JEAN MARIE DILHUYDY, M.D., MARTHE-ALINE JUTAND, M.S.

A longitudinal study enrolled 75 women with primary breast cancer. Before the confirmation of
diagnosis, authors measured trait-anxiety and body satisfaction. Three weeks after diagnosis,
coping strategies and state-anxiety were evaluated. The number of days of survival was measured
10 years after diagnosis. In Cox proportional-hazards models adjusting for severity of disease
and age, high social support and low state-anxiety predicted an increased risk of death from
breast cancer. A significant increased risk of death in women with low scores on the Body Image
Questionnaire appeared only in the univariate model. (Psychosomatics 2007; 48:211–216)

longer survival.7,11–15 However, in a 5-year prospective

O ver the past decades, there has been increasing inter-
est in the association between psychosocial factors
and survival after breast cancer diagnosis. Studies have ex-
amined a wide range of psychological predictors of sur-
vival. Some authors have demonstrated the importance of
depression and anxiety in the progression of breast cancer.
In two retrospective cohort studies, it was found that
women with an unfavorable course of breast cancer had
previously experienced depression.1,2 In contrast, high de-
pression and high state-anxiety were associated with longer
overall survival in the prospective study of Derogatis et
al.,3 but this research included only 35 breast cancer pa-
tients. In six other prospective studies, depression was not
a significant predictor of relapse.4–8 Spiegel and Giese-Da-
vis9 founded 24 published studies testing whether depres-
sion was linked with cancer progression, and 15 reported
positive associations. Although state-anxiety was posi-
tively linked to survival in two studies, no such association
was observed in four others;10 so the evidence for a dele-
terious effect of depression and anxiety on the course of
the disease is not conclusive.
It has also been suggested that coping-strategy traits
such as helplessness and hopelessness can predict a poor
outcome, whereas “fighting spirit” is associated with
study conducted with 587 breast cancer patients, Watson
Laboratories, Inc. et al.16 found that helplessness/hopeless-
ness significantly predicted shorter event-free but not over-
all survival at 5 years. Fighting spirit had no significant
effects on survival. These results were maintained for up
to 10 years of follow-up.8 Therefore, consensus is also
lacking with regard to coping strategies.
The strongest evidence for a relationship between psy-
chosocial variables and survival has been provided by stud-
ies that include a social-support variable. Several qualita-
tive reviews10,17–19 and one metaanalysis20 showed that
perception of social support is a significant predictor of
favorable prognosis. One recent study21 of 2,835 breast
cancer patients found that women with low levels of social
integration before breast cancer diagnosis had a 66% in-
creased risk of all-cause mortality and a twofold increased
risk of mortality from breast cancer.
Received May 30, 2006; revised June 20, 2006; accepted July 13, 2006.
From the University of Bordeaux, Psychology Laboratory, Bordeaux,
France. Send correspondence and reprint requests to Florence Cousson-
Gélie, University of Bordeaux 2, Psychology Laboratory EA 3662, IFR
99, Public Health, 3 Ter Place de la Victoire, 33076 Bordeaux CEDEX,
France. e-mail: florence.gelie@ps.u-bordeaux2.fr
䉷 2007 The Academy of Psychosomatic Medicine

Psychosomatics 48:3, May-June 2007 http://psy.psychiatryonline.org 211

Predictors of Survival in Breast Cancer
Previous studies examining the role of body image
among cancer patients have primarily focused on the psy-
chosocial adjustment of women with breast cancer who
have undergone mastectomy or lumpectomy.22 Surpris-
ingly, little is known about predictive value of body image
on survival.
The general lack of agreement could be due to the fact
that most of the studies exploring the effects of several
psychosocial factors on survival of breast cancer were not
drawn from a clear theoretical model. We therefore decided
to study, with an integrative model, the link between psy-
chological factors and duration of survival. The model is
based on Lazarus and Folkman’s transactional stress
model.23 Having breast cancer is clearly very stressful, so
women develop reactions and strategies to cope with the
situation. According to our transactional model, adjustment
strategies developed by patients to cope with their disease
and treatment can mediate the effects of the antecedents on
the criterion. The objective was to test the relationships
between some psychosocial variables (personality traits;
perceptivo-cognitive, emotional, and behavioral processes)
and survival after breast cancer diagnosis.
METHOD
Patients
Women with non-metastatic breast cancer (Stage II
and III) who consulted an oncologist at the Institute Ber-
gonié in Bordeaux between January 1993 and January
1995 were invited to participate in the study. The inclusion
criteria were age (18 to 70 years old), having suspected
breast cancer, being treated with neo-adjuvant chemother-
apy, and undergoing a local/regional treatment (surgery and
radiotherapy). Patients with metastases, recurrence, or
other cancers were excluded. The selected patients were
asked to take part in a study assessing the emotional and
psychological impact of cancer. Seventy-nine patients ac-
cepted participation; four patients with non-invasive breast
cancer were excluded. Finally, 75 patients were included
at baseline.
Procedure
Variables of the study were assessed three times: The
First Stage (T1) was before disclosure of diagnosis and
treatment.
Evaluation of Antecedents Sociodemographic antece-
dents and stable personality characteristics were estimated
212 http://psy.psychiatryonline.org
by an interview and questionnaires. The Body Image Ques-
tionnaire (BIQ),24 validated in a French sample, assesses
perceptions, feelings, and attitudes regarding one’s body in
terms of satisfaction/dissatisfaction. A factorial analysis of
the responses of our 75 breast cancer patients yielded one
axis, accounting for 26.4% of total variance, identified as
General Body Satisfaction/Dissatisfaction.25 The State–
Trait Anxiety Inventory, Form Y26,27 evaluated anxiety as
a personality trait. Medical data were collected by the nurs-
ing staff: TNM stage, that is, classification evaluating pri-
mary tumor size (T), lymph-node invasion (N), and pres-
ence or absence of distant metastases (M) and hormonal
dependence (presence of progesterone and estrogen recep-
tors) were also reported.
The Second Stage (T2) was 3 weeks after the diagnosis
and treatment plan were determined for the patient.
Evaluation of Mediators The processes describing the
way in which the patients reacted to their disease (per-
ceived social support, coping strategies, and anxiety) were
evaluated by three questionnaires: 1) the Social Support
Scale28,29 measures perceived availability (number of peo-
ple the individual thinks he or she can count on, if neces-
sary) and satisfaction with perceived social support; 2) the
Ways-of-Coping Checklist–R (WCC–R) a revised 27-item
version of the WCC of Lazarus and Folkman,30 assesses
three coping strategies (problem-focused coping, emotion-
focused coping, and seeking social support). This French
adaptation, validated in 468 subjects, established its good
validity, reliability, and internal consistency;31 and 3) the
State–Trait Anxiety Inventory, Form Y,26 validated in
French samples by Bruchon-Schweitzer and Paulhan,27 as-
sesses state-anxiety. In our study, coping responses were
measured by the WCC–R, whereas Watson et al.8,16 eval-
uated coping responses by use of the Mental Adjustment
to Cancer (MAC) scale.
The Third Stage (T3) was 10 years after diagnosis and
treatment.
Evaluation of Criterion Survival was defined by the
number of days between the date of diagnosis and death.
Data were collected from medical records.
Statistical Analysis
Survival analyses were calculated by use of the Cox
proportional-hazards regression model, calculating the
crude hazard ratio (HR) for each individual psychological
measure and the HR adjusted for tumor size, number of
Psychosomatics 48:3, May-June 2007
 Cousson-Gélie et al.

positive lymph nodes, estrogen-receptor status, and age. quantity subscale of the SSQ–6 was associated with in-
So, in the multivariate regression analyses, one psycholog- creased risk of death, but only after adjustment for medical
ical variable and four control variables were included. HR variables (adjusted HR: 1.04; 95% CI: 1.01–1.07). A low
values ⬎1 are presented; these indicate a greater risk of state-anxiety score was associated with lower survival (ad-
mortality (lower survival time). An HR ⬍1 indicates that justed HR: 0.97; 95% CI: 0.94–0.99). We observed no sta-
a 1-unit increase in the predictor variable is associated with tistically significant effects of perceived stress, perceived
a reduced risk of mortality. For patients still alive, survival control, coping strategies, and social support satisfaction
was calculated from the date of diagnosis until last follow- on survival. No significant association was found between
up (10 years), and these patients were censored. the predominant coping response on the WCC–R scale and
The Body Image Questionnaire (BIQ) was dichoto- overall survival.
mized with a standard cut-off to define cases. The cut-off
was the value of the mean plus one standard deviation (SD) DISCUSSION
for each individual score, as defined in the French valida-
tion of the BIQ.24 For the WCC–R scale, we adopted the This study investigated the effects of several psychosocial
variables on survival after a diagnosis of breast cancer.
procedure of Greer et al.12 and Watson Laboratories, Inc.
Like the data of Watson Laboratories, Inc. et al.,8,16 the
et al.16 for the MAC (Mental Adjustment to Cancer) scale,
present findings do not corroborate those reported by Greer
which classified each patient into three categories accord-
et al.12 We observed no effect of coping responses on sur-
ing to her predominant scores in problem-focused coping,
vival. This is interesting because we used another scale to
emotion-focused coping, or seeking social support (stan-
evaluate coping strategies1 and observed no survival dif-
dardized z scores). A patient was classified as having no
ference associated with high WCC–R focused problem-
predominant response when all her standardized scores
coping scores.
were less than 0.
Body satisfaction before the disclosure of diagnosis
was associated with longer survival at 10 years. Body im-
RESULTS
age has proven to be linked to quality of life in studies
The study group consisted of 75 breast cancer patients (Ta-
ble 1). The mean age of the women at the starting-point of TABLE 1. Demographic and Biomedical Status at Enrollment
(Nⴔ75)
the study was 48 years (SD: 9.8). A total of 43 patients
(57.3%) had died during the 10 years of follow-up, 37 of Characteristics N %
breast cancer. In the remaining 6 patients, the cause of Age, years, mean (SD) 48 (9.8)
Marital status
death could not be specified by the hospital, general prac-
Married 61 81.3
titioner, or cancer registry records. Therefore, to analyze Unmarried 3 4
survival at 10 years, we took 69 patients into account: 32 Divorced 6 8
alive (46.4%) and 37 (53.6%) having died of breast cancer. Widowed 5 6.7
Tumor size
Table 2 contains the crude and adjusted HRs of per- T-2 (2–3 cm) 30 40
sonality traits, sociodemographic, and medical antecedents T-3 (3–4 cm) 18 24
for overall survival at 10 years. A high score on the BIQ T-4 (4–5 cm) 27 36
Node stage
was significantly associated with a reduced risk of mortal- N-0 11 14.7
ity in univariate analysis (crude HR: 0.50; 95% confidence N-1 57 76
interval [CI]: 0.26–0.96), but this became non-significant N-2 6 8
N-3 1 1.3
after adjustment for prognostic factors (adjusted HR: 0.79;
Estrogen-receptor positive 29 38.7
95% CI: 0.39–1.61). An increased HR was found for wid- Histopathological grade
owed or divorced women (crude HR: 11.07; 95% CI: 2.14– I 13 17.3
57.20), but this effect became non-significant in multivar- II 45 60
III 17 22.7
iate analysis (adjusted HR: 2.93; 95% CI: 0.96–8.93). None Menopausal status
of the biological parameters (TNM and age) was signifi- Pre-menopausal 47 62.7
cantly associated with length of survival. Only two psy- Post-menopausal 28 37.3
chosocial variables appeared as predictors of survival (Ta-
SD: standard deviation.
ble 3). A high score on the Availability of Social Support

Psychosomatics 48:3, May-June 2007 http://psy.psychiatryonline.org 213

Predictors of Survival in Breast Cancer

comparing mastectomy versus breast-conserving treat-
ments.32 Several authors, such as Carver et al.,33 have sug-
gested that patients adjust less well to breast cancer if they
are greatly concerned about either aspect of their body im-
age. To our knowledge, no research had studied the effects
of body-image on survival. However, this effect became
nonsignificant after adjustment for known prognostic fac-
tors in our study, so this result should be interpreted cau-
tiously.
We found evidence for state-anxiety being predictive
of survival. In contrast, Watson Laboratories, Inc. et al.8,16
found that high helplessness/hopelessness subscale scores
on the MAC scale increased the risk of death. In our study,
anxiety was associated with longer survival. These dis-
crepancies could be due to the fact that state-anxiety mea-
sured in our study included negative affectivity (fears) but
not feelings of helplessness. The STAI–Y state scale mea-
sures the intensity of present anxious reactions. Low state-
anxiety scores indicate that negative affects are absent or
unexpressed. Several studies have established that restric-
tion of emotion in newly diagnosed breast cancer patients
predicts poor outcome.34–37 Weihs et al.38 also found that
restriction of emotion predicted higher mortality in recur-
rent breast cancer.
Surprisingly, high SSQ–6 Availability subscale scores
were associated with an increased risk of death, whereas
social support has been reported elsewhere to reduce the
risk of mortality.4,12,38–45 Only the availability of support

TABLE 2. Results of Cox Proportional-Hazards Regression Analysis for Personality Traits, Medical and Sociodemographic Antecedents,
and Overall Survival at 10 Years
Death/Total (Death Rate) Crude HR (95% CI) Adjusted HR (95% CI)a
Income (REV)
Low 12/27 (44%) 1 1
Medium 18/28 (64%) 1.89 (0.91–3.93) 1.21 0(0.53–2.75)
High 12/19 (64%) 1.68 (0.75–3.75) 1.27 (0.53–3.04)
Marital status (MARI)
Married 33/60 (55%) 1 1
Unmarried 4/9 (44%) 0.74 (0.31–1.74) 0.74 (0.96–8.93)
Widowed/divorced 5/5 (100%) 11.07 (2.14–57.20) 2.93 (0.96–8.93)
Medical antecedents (ANT MD)
None 25/49 (51%) 1 1
Presence 17/25 (68%) 1.52 (0.82–2.82) 1.13 (0.56–2.28)
Body image
⬍83 29/44 (66%) 1 1
ⱖ83 13/30 (43%) 0.50 (0.26–0.96) 0.79 (0.39–1.61)
Predominant coping response
None 6/11 (65%) 1 1
Problem 16/26 (62%) 0.86 (0.40–1.85) 1.28 (0.55–2.94)
Emotion 9/16 (56%) 0.75 (0.31–1.82) 0.59 (0.23–1.51)
Social support 6/15 (40%) 0.50 (0.18–1.34) 0.77 (0.27–2.20)

a
Adjusted for tumor size, number of positive lymph nodes, estrogen-receptor status, and age.
HR: hazard ratio; CI: confidence interval.

TABLE 3. Results of Cox Proportional-Hazards Regression Analysis for Psychosocial Variables and Overall Survival at 10 Years
Crude HR (95% CI) Adjusted HR (95% CI)a
Body image (QIC) 0.98 (0.95–1.02) 1.00 (0.96–1.04)
Trait-anxiety (AT) 0.98 (0.95–1.01) 0.99 (0.96–1.02)
Social support (quantity) (QSS) 1.02 (0.99–1.05) 1.04 (1.01–1.07)
Social support (satisfaction) (SSS) 1.00 (0.93–1.07) 1.03 (0.95–1.11)
Problem-focused coping (COP PB) 0.99 (0.95–1.03) 1.04 (0.99–1.09)
Emotion-focused coping (COP EMO) 0.99 (0.93–1.05) 0.98 (0.92–1.04)
Seeking social support (COP SS) 0.98 (0.92–1.05) 1.04 (0.96–1.12)
Anxiety (AE) 0.97 (0.95–0.9989) 0.97 (0.94–0.99)

a
Adjusted for tumor size, number of positive lymph nodes, estrogen-receptor status, and age.
HR: hazard ratio; CI: confidence interval.

214 http://psy.psychiatryonline.org Psychosomatics 48:3, May-June 2007


(friends, relatives) was significantly related to survival
when controlling for prognostic factors, whereas satisfac-
tion with social support appeared unrelated to survival. Pa-
tients used coping strategies such as the reduction of neg-
ative affects (state-anxiety) and self-reassurance such as
awareness of the availability of social support.
This study only had sufficient power to detect large
HRs. We were unable to establish any predictive effect of
most of the coping strategies, and the effect of satisfaction
with social support on survival has not been established by
our study, a finding coherent with a 6-year Italian follow-
up study.46 Even reasonably large effects may have been
impossible to detect because of the limited power of the
study. Further studies using the same variables need to be
undertaken on similar subjects but with larger samples and
repeated measurements of state-anxiety, coping, and social
support, because these variables could change over time.
The present findings suggest that breast cancer patients
who minimize their negative affects (low state-anxiety,
high perceived availability of social support) have poorer
survival. Suppression of negative emotions induced by a
stressor might be associated with immunological changes,
which, in turn, speed up the evolution of the disease. This
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