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ORIGINAL ARTICLES |
From the Department of Public Health and Caring Sciences (L.-M.P., K.N., P.-O.S., G.B.), Uppsala University, Uppsala Science Park; and the Department of Oncology, Radiology, and Clinical Immunology (B.G.) and Department of Urology (E.B.), University Hospital, Uppsala, Sweden.
Address reprint requests to: Lena-Marie Petersson, MSc, Department of Public Health and Caring Sciences, Uppsala University, Uppsala Science Park, S-751 83 Uppsala, Sweden. Email: lena-marie.petersson{at}pubcare.uu.se
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: Newly diagnosed patients with breast, gastrointestinal, or prostate cancer (N = 442) were included in a randomized, prospective study of the effects (on anxiety, depression, intrusion, avoidance) of rehabilitation approximately 4 months after diagnosis as compared with control patients. Patients were classified as "monitors" or "blunters" on the basis of the MBSS (368 patients, 83%, completed the MBSS).
RESULTS: The expected interaction at postintervention between coping style and experimental condition (ie, rehabilitation or control) was found only for avoidance among breast and prostate cancer patients. Assignment to the rehabilitation or control condition was of no importance for outcome among blunters. Among monitors, the response pattern differed between breast and prostate cancer patients. Prostate cancer monitors seemed to benefit from rehabilitation on all outcome measures, whereas intrusion and avoidance were reduced among breast cancer patients in the control condition. This interaction of diagnosis with condition (rehabilitation or control) among monitors is suggested to be due to demands for diagnosis-specific information during diagnostic work, in the period just after diagnosis, and before treatment decision.
CONCLUSIONS: Only the monitor concept seems useful for predicting response to cancer rehabilitation with a strong information component. However, whether rehabilitation is of benefit depends also on other factors.
Key Words: cancer, • Miller Behavioral Style Scale, • monitor, • blunter, • rehabilitation, • information.
Abbreviations: ANCOVA = analyses of covariance;; GR = group rehabilitation;; HADS = Hospital Anxiety and Depression Scale;; IES = Impact of Event Scale;; IS = individual support;; ISGR = individual support and group rehabilitation;; LSD = least significant difference;; MBSS = Miller Behavioral Style Scale;; SPCG-IV = Scandinavian Prostatic Cancer Group;; SC = standard care.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Information is a very common component of rehabilitative interventions (6, 7), and patients’ most important sources of information are physicians and nurses (8). Teasdale (9) emphasizes that information is a human communication process that depends less on the decoding of semantic information than on the inferences that individual recipients draw from the context. One consequence of this is that information should be adapted to the characteristics of individual patients. Patient age and education are two characteristics of importance. Cancer patients with a low level of general education ask fewer questions but are equally aware of the disease as are patients with a higher level of education (10). Older patients report more information seeking from nonmedical sources (eg, newspapers, television, and friends) than do young patients (11). The most extreme statement of differential effects of information is summed up in the so-called "monitoring/blunting hypothesis," which implies that information has differential effects for patients depending on their "cognitive style" (12).
Two coping styles have been investigated in laboratory studies of uncontrollable stress situations to account for variations in the effect of information on affective state, namely "monitoring" or cognitive scanning, and "blunting" or cognitive avoidance (12). In 1988 Miller (13) investigated these coping styles in relation to stressful gynecological procedures. She concluded that monitors fare better with a high level of information, whereas blunters do better with less information. Several researchers, among them Ludwick-Rosenthal and Neufeld (14), have replicated these findings in other patient groups (eg, first-time cardiac catheterization patients).
Monitoring and blunting have since been studied in a number of healthcare situations and found to be of clinical relevance (15). Studies of monitors and blunters in the cancer field are important for the understanding of patients’ participation in medical decision making, physicians’ recommendations (16), and patients’ anxiousness and satisfaction with information (17). On the basis of the above studies, it has been concluded that the cognitive coping style used in a given situation is related to the level of psychological distress, such as anxiety. Overall, a blunting orientation is associated with less anxiety than is monitoring (17, 18). Monitoring also seems to be associated with greater attention to preventive healthcare measures (18).
Miller et al. (19) have proposed an interactional approach to the study of coping with threatening situations. Thus, an information situation (eg, much or little information) is not positive or negative in itself, but its outcome in terms of reduction of psychological distress depends on the patient’s coping style (19). Miller et al. assumed that these behavioral coping styles are traits, ie, relatively permanent characteristics of a person. The Miller Behavioral Style Scale (MBSS) (12) is one of the most widely used scales for assessment of monitoring and blunting tendencies. The MBSS describes four hypothetical, uncontrollable, nonmedical situations supposed to evoke stress and discomfort. Three scores can be derived from the MBSS: a total monitoring score, a total blunting score, and a sum score calculated by subtracting blunting from the monitoring total. Using a median (or mean) cutoff, a sample may be divided into high and low monitors and blunters, or simply into monitors and blunters, on the basis of the sum score.
The major aim of the present study was to investigate the extent to which the MBSS can be used to differentiate cancer patients who are likely to benefit from rehabilitation efforts with a strong information component from those who are not. This was done in a prospective, randomized study comparing effects of a rehabilitation program with a control condition. Specific aims were to assess the proportion of cancer patients with monitoring and blunting coping styles at the start of rehabilitation; the levels of anxiety, depression, and subjective distress among these subgroups before and after rehabilitation; and possible interactions between coping style (monitoring/blunting) and group assignment (rehabilitation/control) with respect to anxiety, depression, and subjective distress among breast, gastrointestinal, and prostate cancer patients.
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METHODS |
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Patients were randomly assigned to one of four alternatives:1) individual support (IS), including individually adapted cognitive behavioral therapy (20), intensified primary health care (21), and, for patients with gastrointestinal cancers, nutritional support; 2) group rehabilitation (GR), described below; 3) both individual support and group rehabilitation (ISGR); or 4) standard care (SC), ie, the standard care provided to cancer patients in Uppsala County, which includes none of the components of IS or GR.
To increase the statistical power of comparisons between group rehabilitation and no group rehabilitation, patients assigned to rehabilitation (ie, ISGR+GR) were compared with those assigned to no rehabilitation ((ie, the control group, IS+SC) (Table 1). Thus, IS was equally distributed between the comparison groups.
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Procedure
Patients were approached close to their diagnosis (within 3 months), offered the opportunity to participate, and randomly assigned if they agreed. Members of the project staff identified potential participants from waiting lists at the three hospitals in Uppsala County and contacted them after approval from the responsible physician. To obviate any bias in randomization, this procedure was carried out independently by an oncological statistics center.
The Rehabilitation Program
The rehabilitation program started at about 4 months after inclusion and was a group intervention consisting of 8 weekly sessions and a booster session after 2 months (22). For breast cancer patients, rehabilitation groups were mostly diagnosis-specific, whereas prostate and gastrointestinal cancer patients participated in mixed groups. Two information and education sessions covering cancer disease, treatments and side effects, and dietary problems were conducted by an oncologist, a urologist or a surgeon, and a dietitian, respectively. The program also included 6 sessions of cognitive behavioral therapy, which were led by a psychologist and an oncology nurse and included techniques for handling anxiety, problem solving, discovering and challenging automatic negative thoughts, activity planning, and distraction. During all sessions, there were opportunities for patients to discuss their concerns. Half of each session was dedicated to physical training and relaxation, led by a physiotherapist. This comprised relaxation techniques, breathing techniques, and a physical activation program adjusted to the abilities of the members in each group. Home assignments were used to facilitate learning between sessions. Written information material was developed and used throughout. This was especially extensive with respect to medical information about disease, treatments, and side effects.
Measures
The MBSS was completed at entry. Assessments of anxiety, depression, and subjective distress were performed before and 3 months after the start of the rehabilitation program.
Demographic data on age, diagnosis, education, gender, and social status were collected at entry.
The Miller Behavioral Style Scale
The MBSS describes four threatening scenarios, and the patient is instructed to imagine herself or himself in these contexts: at the dentist, taken hostage by a group of armed terrorists, the threat of job loss, and flying in an airplane when something goes wrong. Patients are asked to select all response alternatives that apply to them among eight behaviors related to each situation. Four items are related to monitoring and four to blunting, forming two subscales. Summing all items endorsed on the monitoring subscale yields the monitoring score. Summing all the items endorsed on the blunting subscale gives the blunting score. High and low monitors and blunters are then defined by dichotomizing the group at the mean (23) or median (24). Thus, four combinations of coping strategies are possible: high monitor/low blunter, low monitor/low blunter, high monitor/high blunter, and low monitor/high blunter. The sum score, derived by subtracting the total blunting score from the total monitoring score, was used in all of the present analyses except frequencies of high/low monitoring and blunting (presented in Table 7). Patients were thus categorized as monitors or blunters on the basis of whether they scored above or below the median. The MBSS was translated and adapted, with permission, by the second author.
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2 = 6.31, df = 1, p < .05).
Cronbach’s 
was 0.75 for the MBSS. There was a large variation in the number of patients (range = 29–282) endorsing individual items. Fourteen items were endorsed by fewer than 100 patients, and 12 of these were blunter items. The monitoring and blunting subscales were weakly but significantly correlated (r = 0.21, p < .001). For the sum score scale, the mean value was 4.10 (SD = 3.72, median = 4); patients scoring 
4 were categorized as monitors, and those scoring <4 were categorized as blunters.
The Hospital Anxiety and Depression Scale (HADS) was used for assessment of anxiety and depression. It consists of two subscales: depression (7 items) and anxiety (7 items). Subscale scores range from 0 (no distress) to 21 (maximum distress) (25). The originators suggested a score of 7 or less on either subscale as indicative of a "noncase," 8 to 10 as a "doubtful case," and a score of 11 or more as a "case" of clinically relevant anxiety or depression. In the present study, a score of 8 or more on the respective subscale was considered indicative of a "case."
Subjective distress was assessed by the Impact of Event Scale (IES), developed for the assessment of aspects of posttraumatic stress disorder (26). Two dimensions of current subjective distress originating from a specific life event, in this case the cancer disease, are targeted. The IES is a 15-item scale that measures intrusion (range = 0–35), characterized by unbidden thoughts and/or images of the event, and avoidance (range = 0–40), characterized by denial of meanings and consequences of the event. The patients are asked to estimate the frequency of each item during the last week on a 4-point scale ranging from "not at all" to "often" (26).
Statistical Methods
Comparisons were made between patients randomly assigned to rehabilitation (ISGR+GR) and those randomly assigned to no rehabilitation (ie, control group, IS+SC). Thus, IS was equally distributed between the rehabilitation and control groups and should therefore imply no threat to the validity of the comparison. Analyses were performed on the basis of the intention-to-treat-principle. t tests were used to analyze differences between two independent means. Two-way analyses of covariance (ANCOVA) were used to assess potential interactions between coping style and randomization group with respect to anxiety, depression, intrusion, and avoidance at postintervention. Preintervention measures were used as covariates to control for initial differences. When indicated, the least significant difference (LSD) test was used for post hoc comparisons. Chi-square tests were used for assessment of the independence of coping style and "caseness" of psychological distress. Statistica® software for MacIntosh was used for the analyses.
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RESULTS |
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Using the sum score, 210 patients were categorized as monitors and 158 as blunters. There were no differences between these groups with respect to diagnosis, gender, number of patients below or above 65 years, marital status, education, or randomization groups (Table 2).
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65) by group assignment interactions for breast and prostate cancer patients separately because breast cancer patients were younger than prostate cancer patients (Table 1). There were no significant interactions or main effects (data not shown). Independent t tests at postintervention showed that younger monitors had a higher level of intrusion than did older monitors (mean = 9.4, SD = 6.9 vs. mean = 6.5, SD = 6.3) (t = 3.06, df = 192, p < .01). Among blunters, there was a tendency for younger patients to be less depressed than older patients (NS).
The relative independence of cognitive coping style (monitors/blunters) and anxiety and depression (in terms of HAD case/noncase status) before and after intervention was tested by 2 analyses. Coping style was found to be independent of "caseness" of anxiety and depression (Table 6).
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65 years were categorized as high monitor/high blunter (62 of 180, 34%) rather than low monitor/high blunter (26 of 180, 14%) (2 = 9.21, df = 3, p < .05). |
DISCUSSION |
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The expected interaction between coping style and participation in the rehabilitation/control conditions concerning anxiety, depression, and subjective distress was found only for avoidance. In addition, the response patterns differed between breast and prostate cancer patients. When additional analyses of diagnosis (breast and prostate)-by-rehabilitation/control interactions were performed for monitors and blunters separately, no significant interactions were seen among blunters. Thus, participation in the rehabilitation intervention did not influence the outcome among blunters. However, for monitors there were significant diagnosis-by-rehabilitation/control interactions. Prostate cancer monitors in the rehabilitation group reported reduced problem levels on all outcome variables as compared with prostate cancer monitors in the control condition. In contrast, subjective distress improved among breast cancer monitors in the control group as compared with the rehabilitation condition. We suggest that this interaction between diagnosis and group assignment could be interpreted in terms of differential effects of rehabilitation/information depending on patient realities (eg, time since diagnosis, time since treatment decision, and treatment initiation). It should be noted that although women with breast cancer either had completed their treatment or were under active treatment, about half of the prostate cancer patients were under "watchful waiting." The medical examinations required before a treatment decision generally take several months, and the treatments used (radical prostatectomy, radical combined external and interstitial radiation and hormonal therapy) may result in many side effects. For localized tumors, there is still no treatment of choice. This is a complex situation that creates the need for specific information. Also, it may be difficult for the doctor to decide when enough information has been provided. In the rehabilitation groups, patients had the opportunity to meet other patients in the same situation, and they had ample time to discuss issues with an oncologically oriented urologist. The proportion of prostate cancer patients treated with surgery is artificially reduced in the present study because of the ongoing SPCG-IV study, a randomized study comparing prostatectomy with watchful waiting. Patients in SPCG-IV were excluded from the present study.
Why did breast cancer monitors improve more with regard to subjective distress in the control than in the rehabilitation condition? First, this was not a consistent pattern. Second, at the point of ongoing or terminated treatment monitors may have felt sufficiently well informed by the regular oncological services. Hence, medical information may inadvertently maintain a high level of subjective distress by keeping patients cognitively occupied by the cancer and scenarios more threatening than their own. Monitors tend to amplify potential threats (27). Thus, new threatening scenarios may have appeared plausible. Third, if the information received implies smaller threats than those represented in the existing thoughts, it may be of help for the cognitive process of reality testing. However, if the information received is more threatening than patients’ own thoughts, patients may become anxious (28). The contents and timing of the information may be of considerable importance. Breast cancer monitors became more distressed over time regardless of patient education (29). This suggests that the monitor/blunter hypothesis of the benefits of information may not apply in its simplest form when serious diseases are involved.
The demonstrated interactions between rehabilitation/control and diagnosis among monitors may be confounded by age differences. To test this possibility, rehabilitation/control-by-age (<65 vs.65 years) analyses were performed separately for each diagnosis. There were no interactions but a few differences between age groups. Age did not interact with rehabilitation/control for anxiety, depression, intrusion, or avoidance. Thus, there is no reason to suspect that the differences between the prostate and breast cancer groups can be accounted for by age.
A fact that complicates the interpretation of the present findings is that the rehabilitation intervention included not only an information package but also a cognitive-behavioral therapeutic (CBT) intervention. The positive effect among prostate cancer monitors may therefore not be due to the information component per se but also to the learning, practice, and application of CBT techniques. The failure to influence subjective distress among breast cancer monitors in the rehabilitation group may also be given another interpretation. It is possible that in the group setting, patients perceive many statements by other patients as potentially threatening. If so, this may only partly be handled in the group setting. Threatening thoughts may thus maintain subjective distress, and the CBT component of the intervention may have been insufficient in length to teach cognitive-behavioral techniques properly.
The use of the MBSS in the present context may not be unproblematic. Fourteen items were endorsed by fewer than 100 patients, and 12 of these were blunter items. Thus, with the suggested method of defining a blunter, very few blunting situations need to apply for a patient to be classified as a blunter (30). Another problem is that patients are supposed to mark those statements that apply to them. If a statement is not marked, it is unclear whether it is a missed item or does not apply. Only subjects with at least one marked item for every situation were included in the analyses. Other researchers have found the blunting scale to have poor psychometric characteristics as compared with the monitoring scale (19). Twenty-nine patients in the present study made comments that they could not imagine some of the situations. In contrast to what may have been expected (31), these situations were in descending order: the work item, the flying item, the dentist item, and the hostage item. We found that many older and/or retired patients had difficulties imagining themselves in the work situation, which was no longer appropriate for them. A much smaller number experienced problems with the hostage situation.
In the present study, we chose to compare ISGR+GR with IS+SC. Because individual support was equally distributed in both conditions, it should not present a problem in interpretation of the results. But to explore this possibility, we performed comparisons between the four randomization groups (data not shown). The analyses verified the presented pattern of findings in the ISGR as well as the GR groups. However, with fewer patients in each condition, the interactions often failed to reach statistical significance.
It has been suggested that the correlation between monitoring and anxiety is so high that monitoring could be considered simply a measure of high anxiety (17). If that were the case, the present (and other) attempts to relate monitoring/blunting status to psychological distress would be seriously confounded. Therefore, the relationships between monitoring/blunting status and caseness of anxiety and depression were investigated. These classifications were found to be largely independent (Table 6). Thus, the present analyses do not seem to be confounded by this problem.
In conclusion, the blunting concept of the MBBS scale was of no help in differentiating between patients who benefited from rehabilitation/information and those who did not. Thus, this intervention had no negative (or positive) effect on blunters. However, the monitor concept seems useful for screening patients provided that other factors are considered. The present rehabilitative program was administered approximately 4 months after diagnosis, which was before the initiation of medical treatment for most prostate cancer patients. This situation may be characterized by a higher demand for information than during treatment or after treatment. In contrast, the breast cancer patients were undergoing or had just terminated their treatment. This is suggested to be the reason why the control condition was of most benefit for the breast cancer patients. Thus, providing blunters with extensive medical information poses little to no risk, but for monitors timing should be considered carefully. Periods of uncertainty or decision making, eg, when patients have to decide on treatments, are particularly suited for information.
Received for publication January 16, 2001.
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Patients who were under medical investigation for a suspected breast cancer were informed that GR would be an option only if surgery confirmed a cancer diagnosis.