Jouml of Pqchosomatic Printed I” Great Bntam

SOCIAL

Resenrch, Vol. 36. No. 6, pp U-541,

RELATIONS, AMONG

W22-3999/92 $5.00+.00 Pergamon Press Lfd

1992.

SOCIAL PATIENTS

SUPPORT AND SURVIVAL WITH CANCER

KATHLEEN ELL, ROBERT NISHIMOTO, LINDA MEDIANSKY, JOANNE MANTELL and MAURICE HAMOVITCH (Received

6 August

1991; accepted

in revised

form 5 February

1992)

Abstract-This study examined the relationship between social relationships and social support and survival following a first diagnosis of breast, colorectal, or lung cancer. Findings showed different factors related to survival for those with breast vs lung or colorectal cancer and for those with localized vs non-localized cancers. Results provide important evidence that social relations and social support may operate differently depending on cancer site and extent of disease.

THE BELIEF that human mortality is influenced by the absence or sudden loss of social relationships has been a recurrent theme in psychological, sociological, and medical literature. Two seminal articles reviewing animal and human research concluded that primary social relationships and the coping resources they provide are essential in managing stress and, thereby, in influencing both psychological and physical health [ 1,2 ] . Interest in the association between social relationships and mortality has been spurred further by recent large-scale population-based studies [ 3, 41. These epidemiologic studies have documented associations between social isolation and increased risk of all-cause and cardiovascular mortality [ 5-131. The majority of these studies fail to distinguish whether social ties influence incidence of disease, case fatality or recovery [ 13, 141. More important, these studies do not explain the manner in which social relations may affect mortality [ 151 . Other research has shown that a lack of social relationships is a risk factor following life-threatening illness. In a lo-yr prospective study of 1400 myocardial infarction patients, those who were married at the time of MI were significantly less likely to die during hospitalization and over the following 10 yr [ 161 . In another study, Wiklund and colleagues found that being single increased risk of death after a first MI [ 171. Also high stress in combination with social isolation was found to be associated with higher death rates and poor recovery among 2300 post-MI patients enrolled in the beta-blocker study [ 181. With respect to cancer, Reynolds and Kaplan found evidence linking social relationships to cancer incidence, mortality, and prognosis during 17 yr of follow-up in a population-based sample of 6848 adults [ 191. Socially-isolated women were shown to be at significantly elevated risk of dying of cancer of all sites and of smoking-related cancers. While cancer incidence or mortality were not prospectively associated with social connections among men, men with few social connections showed significantly poorer cancer survival rates. In an analysis of 27,779 cancer

University of Southern California, School of Social Work, Montgomery Ross Fisher Building, Los Angeles, CA 90089-0411, U.S.A. Address for correspondence: Kathleen Ell, 250 The Village, #311 Redondo Beach, CA 90277, U.S.A. 531

532

K. ELL ef al.

cases, unmarried persons with cancer were found to have decreased overall survival, were more likely to be diagnosed at more advanced stages of the illness, and were more likely to be untreated [20]. The poorer survival of unmarried persons remained even after adjusting for cancer stage and treatment. In addition, four case studies [21-241 have examined diRerent indicators of social relations and cancer survival. Three of the studies found a positive association between measures of social relationships and survival, however, in a study of patients with advanced disease, no relationship was found between a measure of social networks and survival [ 221. Inconsistency in the constructs measured, failure to examine whether effects might vary depending on the type of cancer and extent of disease, and lack of attention to possible explanatory variables suggest the need for further study [40]. While studies of social support and recovery from cancer did not examine mortality directly, they suggest that the supports (particularly emotional support) patients receive from family, friends, and health professionals might begin to explain the association between social relationship indicators and mortality [ 25-32 ] . Possible explanations include that social support may reduce negative psychological responses, enhance psychological wellbeing, and influence treatment compliance, health behaviors, and immune and neuroendoctrine function. The study reported here examined prospectively the relationship between two social relationship indicators (material status and social integration) and one social support indicator (perceived adequacy of emotional support from close ties) and survival following a first diagnosis of breast, colorectal, or lung cancer. In addition, patients’ self-reported psychological distress and personal sense of control were assessed. Based on evidence from studies of social network, social support and psychological adaptation to cancer, it was hypothesized that emotional support would be correlated positively with, the a stronger predictor of, survival than social relations and would be negatively associated with psychological distress and positively correlated with sense of control [25-321 . The study design controlled for physical factors and separate analyses were conducted on patients with localized as well as more extensive disease and on patients with breast versus colorectal or lung cancer. STUDY

METHODS

The sample A sequential sample of 369 patients was drawn from the cancer registries of 23 hospitals affiliated with the Cancer Management Network of the University of Southern California’s Comprehensive Cancer Center. Criteria for study participation were: being aged 35 yr or older; being newly diagnosed with breast, lung or colorectal cancer; having no other immediate life-threatening medical illness; having no psychiatric or central nervous system disorder; having their physician’s consent; and, being willing to participate in two interviews over a 6.month period. It was presumed that including people with cancer in these three sites would include people with short-term as well as long-term survival. A more detailed description of sampling procedures is reported elsewhere [ 33-361 Data presented here are from a prospective cohort analysis of 294 patients on whom medical, psychosocial, and survival data were available. Measures were obtained from either the USC Medical data, including site and stage of illness at diagnosis, Cancer Surveillance Center or hospital cancer registries. Cancer staging I-V was used with I including in sift cancers and V including metastases. Survival data were obtained from public death certificates. A death from any cause was considered to be non-survival. For non-survivors the length of time between

Social

support

in cancer

533

the first interview and death ranged from 21 days to 83 months. All other study data were obtained through structured interviews conducted in patients’ homes by experienced graduate-level social workers who had received specific training in administering the study questionnaire. A full description of the questionnaire is reported elsewhere [ 33-361 . Data reported here are from an initial interview obtained within 3-6 months of diagnosis. Socioeconomic status was measured by income, education, and occupational status using Duncan’s Socioeconomic Index (SEI) [ 371. Functional status was assessed using the role-limitation measure previously used in the Rand Health Insurance Study [ 381. In this study, internal consistency reliability of the role limitation scale was 0.88. Psychosocial factors were measured using available instruments with established validity and reliability. In addition to marital status, access to more distant social ties (social integration) (AVSI) (alpha = 0.62) and perceived adequacy of emotional support from close relationships (ADAT) (alpha = 0.75) were measured using two scales from the Interview Schedule for Social Interaction 1391. Psychological distress was measured using the psychological distress subscale (PYSDS) from the Mental Health Inventory (MHI) (alpha = 0.98) developed for the Rand Health Insurance Study [40]. This measure has been used in previous studies of patients with cancer and other serious illness [41-421. Item scale and discriminant validity and the content validity of the MHI are satisfactory [ 401 Construct validity has been demonstrated by its correlations with measures of social support [ 431 , health status [38], and stress [44]. Personal sense of control was determined by a five-item scale assessing the respondent’s personal sense of mastery or ability to solve problems (alpha = 0.64) [45]. Data analysis Univariate and stepwise multivariate analyses were conducted using the Cox proportional hazards model. The analyses were conducted separately for those with breast cancer and for those with colorectal or lung cancer and also for those with localized and non-localized cancers. This was done in order to control for the effects of cancer site and stage respectively. Due to sample size limitations, analyses could not be conducted within groups defined by both site and stage of cancer. Death, regardless of cause, was treated as an event and patients who were alive as of August 1990 were treated as censored observations. Attained significance levels are reported for the univariate analyses and an alpha level of 0.05 is used for the multivariate analyses.

RESULTS

Sample

characteristics

Of the 294 patients, there were 220 survivors and 74 deceased. The majority of patients were female (78%), married (57%) and white (83 %). Age ranged from 35 to 85 yr (mean, = 61 yr). More specifically, 11% were under 45 yr, 2 1% between 45 and 54 yr, 30% between 55 and 64 yr, 22% between 65 and 74 yr, and 15% aged 75 or older. Ranking patients by Duncan’s SEI, 33% were in the lower third, 34% were in the middle third, and 33 % in the upper third socioeconomically. With respect to clinical characteristics, 57% has breast cancer, 26% had colorectal cancer, and 17% had lung cancer. Almost 47% had in situ or localized cancer, 6% had extension cancers, 38% had nodal involvement, and 9% had metastases at time of diagnosis. Comparisons between survivors and deceased found significantly higher numbers of those with lung or colorectal cancer (x2 = 30.34, p = < 0.001) and more advanced cancers (x2 = 39.02, p = < 0.01) among the deceased. Role limitation was also greater among the deceased (t = 2.18, p = < 0.01). There were no differences by education or SEI, however, the mean age of the deceased was 63.6 vs 60 among survivors (t = 2.29, p = c 0.05). There were more females among the survivors (x2 = 23.5 1, p C 0.001) and more married persons among the deceased (x*3.09, p = 0.079). Non-survivors reported less social integration (t = 2.21, p = < O.Ol>, but greater perceived adequacy of emotional support at the initial interview (t = 2.54, p < 0.01). There was no significant difference in degree of psychological distress between survivors and non-survivors. As hypothesized, for survivors and

534

K. ELL et al.

for non-survivors, both emotional support and social integration were negatively correlated with psychological distress (with correlations ranging between -0.18 to 0.37) and positively correlated with personal sense of control (r = 0.22 to 0.33). Univariate

analyses

Table I presents the results of univariate analyses conducted by cancer site of demographic, physical, and psychosocial factors and survival. Two variables, marital status and perceived adequacy of emotional support, only approached significance as factors associated with survival among patients with breast cancer. For those with lung or colorectal cancer, stage of illness was the only significant risk factor impacting on survival. TABLE I.-COMPARISON Variable

Relative risk (et)

Breast Sex* SE1 Marital status? Age Stage Role limitations ADAT AVSI PSYDS Control Lung and colorectal Sex SE1 Marital status Age Stage Role limitations ADAT AVSI PSYDS Control *All subjects tNot married

OF UNWARIATE

MODELS BY SITE 95% C.I.

p

0.996 2.336 0.995 2.143 1.015 0.847 0.853 1.013 0.971

0.69 0.08 0.76 0.11 0.39 0.08 0.15 0.50 0.82

0.965 0.999 0.993 1.003 1.521 1.008 0.980 1.067 1.005 0.881

0.90 0.98 0.98 0.81 0.00 0.68 0.72 0.38 0.71 0.13

with breast cancer was coded 0.

1.16-1.99

were female,

The examination of survival by stage of illness found that among patients with localized cancer, socioeconomic status and perceived adequacy of emotional support were significant protective factors in their survival. (Table II). Survival of patients with advanced cancers was significantly related to being female (a protective factor) and stage of illness (a risk factor) and approached significance in relation to being married. However, the high risk ratio (relative risk > 1) indicates that again, in this analysis, marital status was a risk factor. Multivariate

analyses

Next, stepwise multivariate analyses were conducted by cancer site in order to identify which of the following factors were independently predictive of survival: stage of illness; role limitations; adequacy of emotional support; availability of social

Social

TABLE

II.-COMPARISON

support

OF UNIVARIATE

Relative

Variable

535

in cancer

risk

MODELS

BY STAGE

p

95% C.I.

63 Localized Sex SE1 Marital

cancers 0.922 0.967 0.483 1.010 1810.607 1.125 0.570 0.821 1.005 0.923

status

Age *Stage Role limitations ADAT AVSI PSYDS Control Non-localized cancers Sex SE1 Marital status

*Results variable.

0.366-0.889

0.423 1.005 1.649 1.009 1.907 1.019 0.979 0.986 1.003 0.903

Age Stage Role limitations ADAT AVSI PSYDS Control are not interpretable

0.89 0.04 0.26 0.55 0.76 0.17 0.01 0.31 0.88 0.62

0.935-0.999

0.243-0.737

0.00 0.28 0.09 0.40 0.02 0.38 0.68 0.82 0.78 0.16

1.14-3.20

due to restricted

range

in the

integration; marital status; and psychological distress. As presented in Table III, the multivariate models which emerged differed by cancer site. For patients with breast cancer, marital status was the only significant risk factor and emotional support the only significant protective factor predicting survival. In contrast, stage of illness and role limitations were identified as the only significant risk factors independently affecting the survival of patients with colorectal or lung cancer. TABLE

III.-COMPARISON OF MULTIVARIATE BY SITE Relative risk

Breast ADAT *Marital status Lung and colorectal Stage Role limitations *Not married

was coded

MODELS

P

0.826 2.922

0.03 0.04

1.470 1.067

0.01 0.05

0.

The models which emerged in the analysis by cancer stage also differed (Table IV). For patients with localized cancers, role limitations and adequacy of emotional support contributed significantly to predicting survival. Stage of illness was the only significant predictor of survival among patients with more advanced disease.

536

K. ELL et al. TABLE

W.-COMPARISON

OF MULTIVARIATE BY STAGE

MODELS

Relative

P

Localized cancers ADAT Role limitations Non-localized cancers Stage

risk

0.490 1.204

0.02 0.05

1.882

0.02

DISCUSSION

The reported study extends our understanding of the observed relationship between support and cancer survival and underscores the complexity of the relationship. Results suggest that the emotional support provided by primary network members is a critical factor explaining the relationship between various indicators of social relationship and mortality, a finding consistent with results from previous studies of psychological adaptation to cancer [25-321. At the same time, results provide important evidence that social relations and social support may operate differently depending on cancer site and extent of disease. The multivariate regression models suggest that emotional support from primary network members is protective with respect to survival during earlier stages of disease and among women with breast cancer. No such effect was found at more advanced stages of illness or among lung or colorectal cancer patients. The strength of biological processes over psychosocial processes at advanced stages of illness is underscored. On the other hand, the association between emotional support and marital status and survival among patients with less extensive disease and among women with breast cancer raises numerous questions about the mechanisms by which supportive relationships may influence cancer recovery. The correlations between social support and social integration and psychological distress and personal sense of control are consistent with findings from previous studies of support and psychological adaptation to cancer [ 25-321. However, in this study, psychological distress was not a significant predictor of survival, a finding consistent with previous studies of patients with cancer [22, 24, 46-501 and with a recent population-based study in which no relationship was found between depression and all-cause mortality or specific causes of death [ 5 1 ] . Results from the reported study suggest, therefore, that while support buffers the stress of lifethreatening illness with respect to psychological response, this is unlikely the sole or even the primary mechanism by which support influences survival. An alternative explanation, namely that supports exert their salutary effects by increasing healthy behaviors by patients, such as appointment-keeping and treatment compliance, and by reducing potentially harmful coping behaviors that might be employed to cope with the diagnosis, such as smoking, drinking, and psychotropic drug use was not examined in this study. However, findings from a randomly controlled intervention study employing three different educational support programs (one of which included a family member on the caregiving team) provide evidence that support can influence patients’ behaviors [52] . In this well-designed study, receipt of supportive interventions was an independent predictor of survival, and treatment compliance (also

Social

support

537

in cancer

an independent preditor of survival) was significantly better among experimental patients when compared to control patients. Finally, study results marginally suggest that support may operate differently among yomen and men. For example, in the analysis of women with breast cancer, marital status was found to be a risk factor rather than a protective factor with respect to survival. Perhaps some of these women experienced conflict or stress in their marital relationship that was precipitated by the demands of a life-threatening illness and subsequently impaired their exchange of social support with their partner [ 531. Future research is needed to determine whether or not, and in what ways, support may be influenced by gender [54] Implications Interest in social support and illness prognosis is predicated, in part, on the assumption that psychosocial interventions can influence a patient’s support experience and, in turn, lower morbidity and mortality. A relatively small, but provocative, body of research on strategies to enhance the social support of individuals suggests that social support is amenable to intervention [55] . With respect to recovery from illness or trauma, two randomly controlled studies of crisis intervention with survivors of auto accidents [56] and of MI [57] found significantly better outcomes among experimental subjects, including fewer deaths among the cardiac patients. In the former study, experimental subjects reported higher perceived satisfaction with the support they received from family members, suggesting that support perceptions are amenable to intervention. In addition to the study of compliance behavior [ 521, a recent controlled and methodologically rigorous study of patients with metastatic breast cancer found an association between participation in a weekly support group for a year and length of survival over a period of 10 yr [58]. And Fawzy and colleagues [ 591 have recently demonstrated the effects of a supportive group intervention on the immune function of patients with malignant melanoma. Despite evidence of the effectiveness of professional supportive interventions, however, there is also evidence that many patients do not receive psychosocial interventions. Indeed, in the reported study, only 6% of the patients reported participating in a cancer support group, a finding consistent with other research [ 601. Therefore, health care practitioners are advised to not only implement and evaluate interventions designed to influence the support experience of persons with cancer, but also to develop methods to ensure that these services are accessible to and are received by patients. While findings from this study are provocative, they should be interpreted within the limits imposed by the study’s design. Perhaps, most important, the study does not examine the interactional processes in which social support is exchanged following a cancer diagnosis [ 53, 611 In addition, neither treatment nor patients’ behavioral data were available. Finally, more extensive multivariate analyses, such as within groups defined by both site and stage of illness, could not be conducted due to limitations dictated by sample size. CONCLUSION

Taken together

with results

from previous

research

(Table V), the reported

study

K. ELL et al.

538

provides further evidence that social relations and social support are associated with survival from cancer. This growing body of research is even more provocative, when viewed against the additional background of the previously mentioned population-based studies of cardiovascular disease and all-cause mortality [ 3, 41 as well as the growing number of studies of support and psychological adaptation to cancer [25-321. The experimental studies are most promising insofar as they indicate that patients’ support experience is amenable to intervention [ 52, 581 . TABLE

V.--STUDIES OFSOCIALSUPPORT

Diagnoses

I. Population-based Reynolds and Kaplan (1990) (N = 6848)

II. Clinical

AND CANCER

SURVIVAL

Survival time studied

Measures

Results

17 yr

Be&man and Syme Social Network Index including married vs not; frequency of contacts with relatives; membership in church groups and/or other organizations

Women-socially isolated are at higher risk elevated risk for dying of cancer (all sites) and of smokingrelated cancers

Stress, support, marital status; number friends relatives organizational involvement

Stress and social involvement account for 2 times the variance of stage among women 15-45 yr and 61 and over.

studies All cancers

Men-with few social connections had poorer survival.

studies

Funch and Mettlin (1983) (N = 208)

Breast

Cassileth, Lusk, Miller er al. (1985)

Unresectable pancraetic colorectal glioma gastric, lung

2 yr

A single assessing ties

Neale, Tilley, Vernon (1986) (N = 1261)

Breast

10 yr

Marital

Hislop, Waxler, Coldman et al. (1986) (N = 133)

Metastastic

4 yr

Expressive activities

Expressive activities associated positively with survival.

Goodwin, Hunt, Key er al. (1987) (N = 27,779)

All cancers

5 yr

Marital

Unmarried with decreased survival, more likely to be untreated, and to be diagnosed at advanced stages of disease.

cancer

cancer

20 yr

item social

status

status

i.e. and

No association between survival and psychosocial variables. Widowed patients less likely to survive after controlling for age, SES, stage delay seeking treatment.

(Conrinued).

Social

support

539

in cancer

TABLE V.-Continued Diagnoses

III. Intervention

Survival time studied

Measures

Results

studies

Spiegal, Bloom, Kraemer ef al. (1989) (Treatment Group N = 50; Control N=36)

Metastastic breast cancer

10 yr

Intervention weekly support group therapy for 1 yr

T group mean survival was 36.6 mo.; C group mean was 18.9 mo; Survival diverged 20 mo. after entering study or 8 mo. after intervention.

Richardson, J et al. (1990) (N = 94)

Hematologic cancers

6 months

Intervention education home visit shaping

Complicance and survival higher among experimental groups

Acknowledgement-Portions Cancer Society, California

of this research Division.

were supported

mainly through

a grant from The American

REFERENCES perspective of psychosocial factors in disease etiology. Am J Pub 1. CASSEL, J. An epidemiological Health 1976; 64: 1040-1043. of life stress. Psychosomatic A4ed 1976; 38: 300-314. 2. COBB S. Social support as a moderator and health. Science 1988; 241: 540-545. 3. HOUSE JS. LANDIS KR, UMBERSON D. Social relationships of social support in population surveys. Sot. Sci 4. ORTH-GOMER GK, UNDEN AL. The measurement Med 1987; 24: 83-94. host resistance and mortality: A nine-year follow-up 5. BERKMAN LF, SYME SL. Social networks, study of Alameda County residents. Am J Epidemiol 1979; 109: 186-204. in an elderly community population. Am J Epidemiol 6. BLAZER DC. Social support and mortality 1982; 115: 684-694. of social relationships and activities with 7. HOUSE JS, ROBBINS C, METZNER H. The association mortality: Prospective evidence from the Techmseh Community Health Study. Am J Epidemiol 1982; 116: 123-140. study of social influences on mortality: the 8. WELIN L, TIBBIN G, SVARDSUDD K. et al. Prospective study of men born in 1913 and 1923. Lancer 1985; 1: 915-918. 9. SCHOENBACH VJ, KAPLAN BH, FREDMAN L, KLEINBALJM DG. Social ties and mortality in Evans County, Georgia. Am J Epidemiof 1986; 123: 577-591. 10. SEEMAN TE, KAPLAN GA, KNUDSEN L, et al. Social network ties and mortality among the elderly in the Alameda County Study. Am J Epidemiol 1987; 126: 714-723. J Chron Dis 1987; 40: 11. ORTH-GOMER GK, JOHNSON JV. Social network interaction and mortality. 949-957. 12. KAPLAN GA, SALONEN JT, COHEN RD et al. Social connections and mortality from all causes and from cardiovascular disease: prospective evidence from eastern Finland Am J Epidemiol 1989; 128: 370-380. 13. HANSON BS, ISACSSON SO, JANZON L, LINDELL SE. Social network and social support influence mortality in elderly men. Am J Epidemiol 1989; 130: 100-l 11. support and health: Taking the next step forward. Am J Epidemiol 14. BERKMAN LF. Social networks, 1986; 109: 559-562. 15. COHEN S. Psychosocial models of the role of social support in the etiology of physical disease. Health Psycho1 1988; 7: 269-297. 16. CHANDRA V, SZKLO M, GOLDBERG R, TONASCIA J. The impact of marital status on survival after an acute myocardial infarction: A population-based study. Am J Epidemiol 1983; 117: 320-325. 17. WIKLUND I, ODEN A, SANNE H, ULVENSTAM, WILHELMSSON C, WILHELMSEN L. Prognostic importance of somatic and psychosocial variables after a first myocardial infarction. Am J Epidemiol 1988; 128: 786-795.

540

K. ELL et al.

influences on 18. RUEERMAN W, WEINBLATT E, GOLDBERG JD, CHAUDHARY BS. Psychosocial mortality after myocardial infarction. New Engl J Med 1984; 13A: 641-654. and risk for cancer: Prospective evidence from the 19. REYNOLDS P, KAPLAN GA. Social connections Alameda County study. Behav Med 1990; 16: 101-I 10. 20. GOODWIN JS, HUNT WC, KEY CR, SAMET JM. The effect of marital status on stage, treatment, and survival of cancer patients. JAMA 1987; 258: 3125-3130. 21. FUNCH DP, MARSHALL J. The role of stress, social support and age in survival from breast cancer. J Psychosom Res 1983; 27: 77-83. correlates of survival 22. CASSILETH BR, LUSK EJ, MILLER DS, BROWN LL, MILLER C. Psychosocial in advanced malignant disease? New Engf J Med 1985; 312: 1551-1555. 23. NEALE AV, TILLEY BC, VERNON SW. Marital status, delay in seeking treatment and survival from cancer. Sot Sci Med 1986; 23: 305-312. significance of 24. HISLOP TG, WAXLER NE, COLDMAN AJ, ELWOOD JM, KAN L. The prognostic psychosocial factors in women with breast cancer. J Chron Dis 1987; 40: 729-735. of two dimensions of social support to the psychological 25. BLOOM JA, SPI~ZEL D. The relationship well-being and social functioning of women with advanced breast cancer. Sot Sci Med 1984; 19: 831-837. adjustment to pelvic exenteration. 26. DEMSEY GM, BUCHSBAUM HJ, MORRISON J. Psychosocial Gvnoecol Oncol 1975; 3: 325-334. and their 27. DUNKEL-SCHETTER C. Social support and cancer: tindings based on patient interviews implications. J Sot Iss 1984; 49: 77-98. distress in reaction to lung cancer as a 28. QUINN ME, FONTANA AF, REZNIKOFF M. Psychological function of spousal support and coping strategy. J Psychosoc Oncol 1986; 4: 79-90. of social support among patients 29. SMITH EM, REDMOND R, BURNS TL, SAGERT KM. Perceptions with recently diagnosed breast, endometrial. and ovarian cancer: an exploratory study. J Pyschosoc Oncol 1985; 3: 65-81. 30. TAYLOR SE, DAKOF G. Social support and the cancer patient. In 7&e Social Psychology ofHealth (Edited by SPACAPAN S, OSKAMP S.). Beverly Hills: Sage, 1988. 31. LICHTMAN RR, TAYLOR SR, WOOD JV. Social support and marital adjustment after breast cancer. J Psychosoc Oncol 1987; 5: 47-74. 32. NEWLING SJ, WINEFIELD NR. Social support and recovery after surgery for breast cancer: frequency and correlates of supportive behaviors. Sot Sci Med 1988; 27: 385-392. analysis of psycho33. ELL K, NISHIMOTO R, MORVAY T, MANTELL J, HAMOVITCH M. A longitudinal logical adaptation among survivors of cancer. Cancer 1989; 63: 406-413. 34. ELL K, NISHIMOTO R, MANTELL J, HAMOVITCH M. Social support, sense of control and coping among patients with breast, colorectal or lung cancer. J Psychosoc Oncol 1989; 7: 63-89. and 35. ELL K, NISHIMOTO R. Coping resources in adaptation to cancer: an analysis of socioeconomic racial differences. Sot Ser Rev; 63: 433-446. analysis of psychological adaptation 36. ELL K, NISHIMOTO R, MANTELL, HAMOVITCH M. Longitudinal among family members if patients with cancer. J Psychosom Res 1988; 32: 429-438. index for all occupations. In Occupations and Social Status (Edited 31. DUNCAN OD. A socioeconomic by Rmss J, DUNCAN OD, HATT PK, NORTH CC.) New York: Free Press, 1961. and Measuremenr of Health 38. WARE J, JOHNSON S, DAVIES-AVERY A, BROOK R. Conceptualization for adults in the Health Insurance Study: Mental Health Vol III. Santa Monica: The Rand Corporation, R-1987/3-HEW, 1979. 39. HENDERSON S, BRYNE DG, DUNCAN-JONES P. Neurosis and rhe Social Environment. New York: Academic Press, 1981. 40. VIET C, WARE J JR. The structure of psychological distress and well-being in general populations. J Consult Clin Psycho1 1983; 51: 730-742. 41. SCHMALE AH, MORKOW GR, SCHMITT MH, ADLER LM, ENELOW A, MURAWSKI BJ, GATES C. Well-being of cancer survivors. Psychosom Med 1983; 45: 163-169. 42. CASSILETH BR, LUSK EJ, STROUSE TB, MILLER DS, BROWN LL, CROSS PA, TENAGLIA AN. Psychosocial status in chronic illness. New Engl J Med 1984; 311: 506511. 43. DONALD C, WARE J JR. The Quant$cation of Social Contacts and Resources. Santa Monica: The Rand Corporation, R-2937-HHS, 1982. 44. WILLIAMS A, WARE J JR, DONALD C. A model of mental health, life events, and social supports applicable to general populations. J Healrh Sot Behav 1981; 22: 324-336. 45. ELL K, HAYW~OD LJ. Social support and recovery from myocardial infarction: a panel study. J Sot Ser Res 1984; 4: 1-19. 46. GREER S, MORRIS T, PETTINGALE KW. Psychological response to breast cancer: effect on outcome. Lancer 1979; 2: 785-787.

Social

47. DER~GATIS LR, ABELOFF MD, time in metastatic 48. 49.

50. 5 1.

52. 53.

54.

breast cancer.

support

541

in cancer

MELISARATOS N. Psychological JAMA 1979; 242: 1504-1509.

coping

mechanisms

and survival

PETTINCALE KW, MORRIS T, GREER S, HAYBITTLE JL. Mental attitudes to cancer: an additional prognostic factor. Lancet 1985; 1: 750. JAMESON RN, BURISH TG, WALL~TON KA. Psychogenic factors in predicting survival of breast cancer patients. J Clin Oncol 1987; 5: 768-772. RICHARDSON JL, ZARNEGAR Z, BISNO B, LEVINE A. Psychosocial status at initiation of cancer treatment and survival. J Psychosom Res 1990; 34: 189-201. ROBERTS RE, KAPLAN GA, CAMACHO TC. Psychological distress and mortality: Evidence from the Alamade County Study. Sot Sci Med 1990; 31: 527-536. RICHARDSON JL, SHELTON DR, KRAILO M, LEVINE AM. The effect of compliance with treatment on survival among patients with hematologic malignancies. J Clin Oncol 1990; 8: 356-364. COYNE JC, ELLARD JH, SMITH DAF. Social support, interdependence, and the dilemmas of helping. In Social Support: An Interactional View (Edited by SARASON BR, SARASON IG, PIERCE GR). New York; Wiley, 1990. SCHUMAKER SA, HII.L DR. Gender differences in social support and health. in press; Health

Psychol. 55. GOTTLIEB BJ. Marshulling

social support: Formats, Processes and Effects. Newbury Park. Sage Publications, 1988. 56. PORRITT D. Social support in crisis: quantity or quality? Sot Sci Med 1979; 13A: 715-721. 57. FRASURE NS, PRINCE R. The Ischemic Heart Disease Life Stress Monitoring Program: impact on mortality Psychosom Med 1985; 47: 431-445. 58. SPIEGEL D, BLOOM JR, KRAEMER HC, GO~THEIL E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancer 1989; 2: 888-891. 59. FAWZY FI, KEMENY ME, FAWZY NW, ELASHOFF R, er al. A structured psychiatric intervention for cancer patients: changes over time in immunological measures. Arch Gen Psycho! 1990; 47: 729-735. 60. TAYLOR SE, FALKE RL, SHOPTAW SJ, LICHTMAN RR. Social support, support groups, and the cancer patient. J Consult Clin Psych 1986; 54: 608-615. 61. SARASON BR, SARASON IG, PIERCE GR (Editors) Social Support: An Interactional View. New York: Wiley,

1990.

Social relations, social support and survival among patients with cancer.

This study examined the relationship between social relationships and social support and survival following a first diagnosis of breast, colorectal, o...
814KB Sizes 0 Downloads 0 Views