Coping and stress management training with special focus on women with breast cancer

Background: People diagnosed with cancer are confronted with many stressors, such as worries about diagnosis and prognosis, demanding treatments, treatment decisions, and disruption of ordinary life functions and roles. Compared to other types of cancer, breast cancer affects relatively young women, half of them of working ages. Knowledge of effective strategies to cope with breast cancer, as well as development of interventions strengthening stress management skills among women with breast cancer, are important in order to decrease individual suffering and facilitate the transition back into everyday life, including work.

Aims: The general aim of this thesis was to generate more knowledge regarding psychological and social aspects of being diagnosed with breast cancer. More specifically, the aims were to examine sickness absence and disability pension after diagnosis, how different ways of coping with breast cancer are linked to health outcomes, and ways to promote mental health after diagnosis.

Methods: Study I: All 3547 women in Sweden aged 20-65 with a first breast cancer diagnosis in 2005 and a matched comparison group were followed by register linkage regarding annual levels of diagnosis-specific sickness absence and disability pension through 2010. Associations with disease-related and sociodemographic factors were estimated using logistic regression. Study II: 78 studies were included in a meta-analysis ofassociations between different strategies to cope with a breast cancer diagnosis and health outcomes. The influence ofpotential moderators was also studied. Study III: People with cancer (76% with breast cancer) were randomized to a mindfulness-based stress management training program (n=32) or a wait-list control condition (n=39). Effects on psychological processes and mental health outcomes after six months were analyzed. Study IV: University students participating in a feasibility study of an Internetbased version of the mindfulness-based stress management training program were randomized to the intervention (n=46) or an active control condition (n=44). Completion rate, participant experiences, and post-intervention effects on mental health were assessed.

Results: Study I: Sickness absence, mainly due to breast cancer, increased markedly in the first year after breast cancer diagnosis, however, it approached the levels of breast cancer-free women five years later. Pre-diagnosis sickness absence and advanced cancer stage were associated with higher risk of sickness absence and disability pension, as were lower education and being born outside of Sweden. Study II: Adaptive coping, such as acceptance and positive reappraisal, was associated with better mental health in women with breast cancer. These associations were strongest among individuals under current treatment and women assessed soon after diagnosis. Study III: No significant effect of the mindfulness-based stress management training program on mental health outcomes was found at the six-month follow-up. However, a positive effect on self-reported mindfulness was observed. Study IV: The Internet-based mindfulness-based stress management training program was experienced as usable and acceptable and had potential for increasing psychological well-being for those completing it. However, only 39% of the participants completed the program.

Conclusions: Among women diagnosed with breast cancer, levels of sickness absence were back to the same levels as before diagnosis in a few years. Adaptive coping was associated with better mental health among women with breast cancer, especially during treatment and in newly diagnosed women. Despite increase in mindfulness at six-month follow-up after a mindfulness-based stress management training program, no statistically significant improvement in mental health was found. More knowledge is needed on the underlying mechanisms and moderating factors for achieving long-term benefits ofthis kind oftraining. The Internet could be a promising way to disseminate programs and tools facilitating mindfulness training, but if retention and compliance is important, additional modification of the assessed Internet-based mindfulness-based stress management training program is needed.

List of scientific papers

I. Kvillemo P, Mittendorfer-Rutz E, Bränström R, Nilsson K, Alexanderson K. Sickness absence and disability pension following breast cancer diagnosis: a five-year nationwide cohort study. [Manuscript]

II. Kvillemo P, Bränström R. Coping with breast cancer: a meta-analysis. PloS One. 2014 Nov 25:9(11):e112733.
https://doi.org/10.1371/journal.pone.0112733

III. Bränström R, Kvillemo P, Moskowitz JT. A randomized study of the effects of mindfulness training on psychological well-being and symptoms of stress in patients treated for cancer at 6-months follow-up. International Journal of Behavioral Medicine. 2012;19(4):535-42.
https://doi.org/10.1007/s12529-011-9192-3

IV. Kvillemo P, Brandberg Y, Bränström R. Feasibility and outcomes of an Internet-based mindfulness training program: a pilot randomized controlled trial. JMIR Mental Health. 2016;3(3):e33.
https://doi.org/10.2196/mental.5457