Journal of Psychosomatic Research, Vol. 19, pp. 229 to 234. Pergamon Press, 1975. Printed in Great Britain

PSYCHOLOGICAL AND LIFE-EXPERIENCE DIFFERENCES BETWEEN ISRAELI WOMEN WITH BENIGN AND CANCEROUS BREAST LESIONS JACOB SCHONFIELD” (Received

2 June 1975)

PREVIOUS studies have maintained, either on the basis of clinical [l] or statistical [2] evidence that certain kinds of cancer patients have suffered a loss of a significant other in the years preceding the onset of cancer. The loss experienced may range from death [2] through threatened separation from spouse or even threatened loss of job [l]. Unfortunately in the clinical study cited above no control group was studied so one has no idea if the frequency of threatened separation from spouse or threatened loss of job is any greater among cancer patients than among the population at large. In the statistical study [2], although the death rate from cancer among females in the British Isles appears to be greater per 100,000 among widowed and divorced women, this is only the case when all female deaths from cancer for the years 1930-1932 are combined. When one examines the death rates for different kinds of cancer during these years separately, one finds that in the case of breast cancer the highest rates appear among unmarried women in all age groups above 45 yr [3]. Why widowed women, who according to the loss hypothesis should have the highest cancer rates, do not have the highest rate for breast cancer is not clear. Other clinical studies of breast cancer patients have used control groups [4, 51, but the tendency has been to use an unstructured interview, which makes replication difficult, although in one case inter-rater reliability on an unstructured interview was quite high [5]. The present study is an attempt to improve the methodology in psychological studies of cancer patients through the use of standardized questionnaires administered prior to a breast biopsy. In addition to psychological measures the Holmes-Rahe Schedule of Recent Experience (SRE) [6], was administered to get at some of the recent life events of these biopsy patients.

SUBJECTS AND MATERIALS Interviews with 112 Israeli women with suspicious lesions of the breast took place on the day prior to biopsy. These interviews were held at five different hospitals in the Tel Aviv area. The only criterion for exclusion from the study was inability to speak or to understand Hebrew, the language in which all interviews were conducted. Excluded for this reason were 35 women, who when compared with those included in the study were found to be significantly older and more recent immigrants. Thus no claim is made that the sample studied is representative of all Israeli women with suspicious breast tumors. A Hebrew translation of the Holmes-Rahe Schedule of Recent Experience [6] was read to each subject and experiences reported during the past three years were recorded. A separate sample of 33 non-hospitalized Israelis were asked to assign weights to each item in this scale, using a Hebrew translation of Holmes and Rahe’s original instructions [6]. Subjects were then read, or read them*Department of Rehabilitation Maryland 21201, U.S.A.

Medicine,

University

229

of Maryland

Medical School, Baltimore,

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SCHONFIELD

selves, 68 items from a Hebrew translation of the MMPI [7]. These items could be combined into scales measuring severe depressive tendencies [8], sense of well-being [9], as well as the traditional Lie scale [7]. Finally all subjects were read, or read themselves, a Hebrew translation of the IPAT scale for measuring chronic anxiety [lo]. This scale contains 40 items, the first 20 being covert measures of anxiety, the second 20 being more overt measures (e.g. I tend to get over-excited and ‘rattled’ in upsetting situations). All 40 items correlate highly with other traditional methods of assessing clinical anxiety [1 I]. RESULTS Pathological analyses of the frozen sections taken at the time of biopsy showed that 27 women in the interviewed sample had malignant tumors, necessitating removal of the breast, while the remaining 85 women interviewed had benign tumors that were simply excised. The rate of malignant lesions was significantly higher (p < 0.05) among the older women. Israeli statistics for the general female population also indicate that the rate of breast cancer among women of European or American origin is 3.5 times as high as that among women born in North Africa or Asia (including Israel) [12]. In view of these facts it was felt advisable to divide the present sample at the median age (= 42 yr) of the whole group, and then divide it by place of birth. Table 1 shows the distribution of patients resulting from these divisions, by post-biopsy status. TABLE

1.-POST-BIOPSY

STATUS OF~SRAELIWOMEN

BYAGEAND

Cancerous 42 yr 43 yr and under and over European-American African-Asian Total

1 5 6

PLACEOFBIRTH

Benign 42 yr 43 yr and under and over

17 4 21

18 32 50

23 12 35

A three-way analysis of variance (age x birthplace x diagnosis) was performed on all the variables listed in the materials section above. Tables 2 through 4 show the statistically significant findings. TABLET.-ANALYSISOFVARIANCEOF

Age (4 Birthplace (B) Diagnosis (D) AxB AxD BxD AxBxD Residual *p < 0.10.

MMPIL

SCALESCORES

Sums of souares

Degrees of freedom

0.05 21.91 3.12 0.02 8.71 10.69 0.01 325.59

l/l04 l/104 l/104 l/104 l/l04 l/l04 l/104 104

F value 0.02 7.ooi 1.00 0.01 2.788 3.41* 0.01

t p < 0.01.

As can be seen in Table 2 there was a significant difference on the MMPI Lie scale by birthplace. Women of European or American origin had significantly higher lie scores on this scale when compared with women of North African or Asian origin. There was also a significant interaction (p < 0.10) between place of birth and diagnosis (B x D) on this variable. Cancer patients of European or American origin scored somewhat higher on the Lie scale than benign patients of similar origin. This was not true of the women born in North Africa or Asia. Similarly the Fvalue for the interaction between age and diagnosis (A I: D) was larger than would be expected at the p < 0.10 level. Among patients under 42yr of age, those with malignant tumors had somewhat higher MMPI Lie scale scores than those with benign tumors. In the group of women over 42 yr of age there was hardly any difference between the benign and cancerous patients in scores on the MMPI Lie scale. No statistically significant differences were obtained either by diagnosis, birthplace or age on the other two MMPI variables-the measure of severe depression and the measure of well-being.

Differences between Israeli women with benign and cancerous breast lesions

231

Table 3 shows that a significant difference was found on the measure of covert anxiety by age Women under 42 yr of age had signiticantly higher covert anxiety scores than women over 42 yr of TABLE

%--ANALYSIS

OF VARIANCE OF COVERT SCORES

Age (A) Birthplace (B) ~iaxgnsosis (D)

Sums of squares 445.88 1.07 100.37 21.16

AxD BxD AxBxD Residual

116.94 4.89 1.90 3496.89

ANXIETY

Degrees of freedom? l/90 l/90 l/90 l/90 l/90 l/90 l/90 90

SCALE

F value

11*47t 0.03 0.54 2.58 3.01* 0.12 0.05

*p < 0.10. tP < 0.01. 14 patients did not complete this scale. age. There was also a significant interaction (p < 0.10) by age and diagnosis (A x D). In the under 42 yr age group, the cancer patients had significantly higher covert anxiety scores than the benign patients. This was not true among the women over 42 yr of age. No statistically significant differences were found on the measure of overt anxiety, or when overt and covert anxiety scores were combined into a total anxiety score. Since less than 50 per cent of the patients were engaged in full-time employment outside their homes, Life Change Unit scores for all subjects were calculated after omitting six items in the Schedule of Recent Experience dealing with job problems. Table 4 shows the results of this analysis. TABLE

&-ANALYSIS

Age (A) Birthplace (B) Diagnosis (D) AxB AxD BxD AxBxD Residual

OF VARIANCE OF LIFE CHANGE FORPASTTHREEYEARS

Sums of squares

Degrees of freedom

1.0 13640 16,246.0 157.0 197.0 1263.0 4536.0 427,863.O

l/104 l/104 l/104 l/104 l/104 l/104 l/104 104

UNIT SCORES

F value

O+O 0.33 3.95’ 0.04 0.05 0.31 1.10

*p < 0.05. As can be seen in Table 4 there was a significant difference in LCU scores by diagnosis, irrespective of age or birthplace. Patients subsequently found to have benign tumors had significantly higher LCU scores than patients found to have malignant tumors. A separate examination of 5 items on the SRE dealing with loss and separation (i.e. death of spouse or close family member, divorce or separation from spouse, child leaving home), showed no statistically significant differences in the reported experience of such events in the past 3 yr between the benign and cancerous patients. DISCUSSION

The finding of significantly higher MMPI Lie scale scores among Israeli women of European or American background (Table 2) seems to indicate that this scale is somewhat culture-bound. Among the women on whom the scale was standardized (i.e. Westerners) there is some evidence that women found subsequently to have malignant tumors of the breast are more likely to score high on this scale than women found to have benign tumors. According to Dahlstrom et al. [13] the Lie scale of the

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SCHONFIELD

MMPI measures denial of aggression, weakness of character, and poor self control. Thus the finding of such denial among cancer patients of European or American origin would extend the findings of Huggan [14] and Bahnson [15] of greater denial among patients with known cancers back to their premorbid condition before they had any knowledge of their disease status, at least among Israeli women of European and American origin. The lack of significant differences between cancer and benign patients on MMPl measures of depression and well-being is not too surprising. A previous study showing higher depression scale scores has been reported only among patients known to have cancer [16], many of whom were aware of their disease, while patients in the present study were still unsure of their medical status at the time they were interviewed. The finding of higher covert anxiety scores among younger Israeli women (Table 3) may be an indication of the greater significance attached to the breast by younger women, reported by other researchers [17]. The further finding of higher scores on this measure of covert anxiety by younger patients subsequently found to have malignant tumors may be the result of their picking up cues from their doctor about the seriousness of the lump he discovered in their breast. It is known that a physician’s anxiety in finding such a lump may be transferred to his patient despite any reassurances he may give [18]. The higher score on the Lie scale found among these younger women (see Table 2) may also be seen as defense mechanism against bringing to full awareness the underlying message behind the examining physician’s attempt to reassure her. In an earlier study by the author using the same measure of anxiety, it was found that cancer patients with higher covert anxiety scores were less likely to return to their earlier life-style one year after treatment when no evidence of the original disease was found [19]. If the women in the younger age group with malignant tumors continue to show higher covert anxiety scores and higher MMPI Lie scale scores after their mastectomy operation, it would seem that there is considerably less likelihood they would resume earlier patterns of living that include employment outisde the home. The lack of confirmation of the hypothesis of the loss of significant others among the malignant tumor patients is not too surprising in view of Muslins et al. failure to substantiate this hypothesis in a similar study of breast cancer patients and controls [20]. More surprising perhaps is the finding of higher Life Change Unit scores among the subsequently benign patients. Of course it is possible that the sample of Israelis from whom LCU weights were obtained (N = 33) was too small and the resulting tied scores among items distorted these data. However, examination of the rank ordering of the top 10 items shows greatest agreement with a Danish sample (60 per cent) and almost as much agreement (50 per cent) with a Caucasian American and Swedish sample [21]. It is of interest to note that when the subsequently benign and cancerous patients were compared on the number of items they reported that fell into the top 10 LCU ranks, no significant difference was found between them. However when a similar comparison was made for the bottom 10 LCU ranking items, the benign patients reported significantly (p < 0.05) more of them. This study therefore provides no support for the contention that patients with malignancies have experienced more stressful events in the years immediately prior to the development of their disease, if one compares them with women who develop benign lesions in the same location.

Differences between Israeli women with benign and cancerous breast lesions

233

SUMMARY One day prior to a breast biopsy for a suspicious tumor, 112 Israeli women were given a Hebrew version of the MMPI Lie, Morale Loss (severe depression) and Wellbeing scales. They were also given Hebrew translations of the IPAT scales of overt and covert anxiety as well as Holmes and Rahe’s Schedule of Recent Experiences (SRE). Pathological analyses revealed that 27 of these women had malignant tumors, while the remaining 85 had benign ones. The sample was divided at the median age (42 yr) and by birthplace (European and American vs Middle East) due to the higher breast cancer rates reported in the older and Western born population. Among women born in Europe or America, patients subsequently found to have malignant tumors had higher scores on the MMPI Lie scale. This was interpreted as being indicative of the greater need for denial of the possibility of having a malignancy in this group of women. No significant differences were found either by age, birthplace or diagnosis (malignant vs benign) on the MMPI measures of severe depression (Morale Loss) or Well-being. Younger patients (under 42 yr of age) were found, irrespective of their birthplace, to score higher on the measures of covert anxiety. This was interpreted as being a result of the greater significance of possible loss of a breast among these younger patients. Higher covert anxiety and MMPI Lie scale scores were also observed in younger patients subsequently found to have a malignant tumor. These in turn were seen to be possibly a result of their physician’s unconsciously transmitting to them his own anxiety about the lump found in their breast. No support was found in the present study for the contention that cancer patients have suffered ‘losses’ of signicant others in the years preceding the development of their malignant tumor. In fact it was found that the patients who were subsequently found to have benign tumors scored significantly higher on the SRE measure of recent events requiring either major or minor adjustment. Ackno~t’ledgemerzfs-Drs. Bindman, Izsak, Mozes, Tolchinski and Urcar kindly gave me permission to interview their breast biopsy patients. Mr. I. Montag provided Hebrew translations of the MMPI and the IPAT anxiety test. Miss Ora Bialik and Mrs. Sara Shachor were kind enough to translate into Hebrew the items from the Schedule of Recent Experience as well as the instructions for weighting each item. Professor Jack Medalie provided continual support throughout the course of the whole study. REFERENCES 1. GREENEW. A. The psychosocial setting of the development of leukemia and lymphoma. Ann. N.Y. Acad. Sci. 125, 794 (1966). 2. LESHAN L. Loss of cathexes as a common psychodynamic characteristic of cancer patients: An attempt at statistical validation of a clinical hypothesis. Psycho!. Rep. 2, 183 (1956). 3. PELLERS. Cancer and its relation to pregnancy, to delivery, and to marital status: 1. Cancer of the breast and genital organs. Surg. Gyn. Obst. 71,l (1940). ~..MUSLIN H. L. Separation experience and cancer of the breast. Psychosomatics 3,230 (1962). KATZ J. L.. WEINERH.. GALLAGHERT. F. and HELLMANL. Stress, distress and ego defenses: Psychoenddcrine responses to impending breast tumor biopsy. Arch. Gen. Psychiat. 23, 131 (1970). HOLMEST. H. and RAHE R. H. The social readjustment rating scale. J. Psychosom. Res. 11,213 (1967).

HATHAWAYS. R. and MCKINLEYJ. C. Minnesota Multiphasic Personality Inventory. Psychological Corporation, New York (1951). CANTERA. The efficacy of a short form to evaluate depression and morale loss. J. Consult. Psychol. 24, 14 (1960).

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9. STEINK. B. and CHU C. Dimensionality of Barron’s ego strength scale. J. Consult. Psychol. 31, 153 (1967). 10. CATTELLR. B. and SCHEIRI. H. Handbook for the ZPAT Anxiety Scale (Self analysis form). Institute Personality Ability Testing, Champaign, III. (1963). 11. CA-~TELLR. B. and SCHEIRI. H. Clinical validities by analyzing the psychiatrist exemplified in relation to anxiety diagnosis. Am. J. Orthozwchiat. 28.699 (1958). 12. Statistical Abstract of%rael, p. 98 (1970): _ 13. DAHLSTROMW. G., WE-H G. S. and DAHLSTROML. E. An MMPI Handbook, Vol. 1, p. 109. University of Minnesota Press, Minneapolis (1972). 14. HUGGAN R. E. Neuroticism, distortion and objective manifestations of anxiety in males with malignant disease. Br. J. Sot. Clin. PsychoI. 7, 280 (1968). 15. BAHN~~NM. B. Ego defenses in cancer patients. Ann. N.Y. Acad. Sci. 164,546 (1969). 16. BLUMBERGE. M., WE= P. M. and ELLIS F. W. A possible relationship between psychological factors and human cancer. Psychosom. Med. 16, 277 (1954). 17. WEINSTEINS., SERSENE. A., FISHERL. and VENTERR. J. Preference for bodily parts as a function of sex, age and socio-economic status. Am. J. Psychol. 77,291 (1964). 18. COPE O., WANG C. and CAROA. Emotional problems commonly encountered in general surgery. Intl. Psychiat. Clin. 4, 3 (1967). 19. SCHON~ELDJ. Psychological factors related to delayed return to an earlier life-style in successfully treated cancer patients. J. Psychosom. Res. 16,41 (1972). 20. MUSLIN H. L., GYARFASK. and PEIPER W. J. Separation experience and cancer of the breast Ann. N.Y. Acad. Sci. 125, 802 (1966). 21. RAHE R. H. Multi-cultural correlations of life change scaling: America, Japan, Denmark and Sweden. J. Psychosom. Res. 13, 191 (1969).

Psychological and life-experience differences between Israeli women with benign and cancerous breast lesions.

Journal of Psychosomatic Research, Vol. 19, pp. 229 to 234. Pergamon Press, 1975. Printed in Great Britain PSYCHOLOGICAL AND LIFE-EXPERIENCE DIFFEREN...
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