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ORIGINAL ARTICLES |
From the University of Iowa, Iowa City, Iowa (E.S.C., S.K.L., S.L.B.); and the University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.L.R., B.A.).
Address correspondence and reprint requests to Susan K. Lutgendorf, PhD, Department of Psychology, E11 Seashore Hall, University of Iowa, Iowa City, IA 52242. E-mail: susan-lutgendorf{at}uiowa.edu
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONNOTESREFERENCES |
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Methods: Participants completed questionnaires assessing depressive symptoms, anxiety, health behavior, and beliefs about factors that may have caused their cancer and prevented recurrence.
Results: Genetics/heredity was rated as the most important cancer cause, followed by stress, God’s will, hormones, and environmental factors. Medical screening was rated as most important in preventing recurrence, followed by positive attitude and prayer. Stronger causal attributions were generally associated with elevated depressive symptomatology and anxiety, but women citing potentially controllable causes were more likely to be practicing healthy behaviors. Similarly, women citing health behaviors as important in preventing recurrence reported greater anxiety but were more likely to practice positive health behaviors. Health behavior and lifestyle attributions interacted with health practices in predicting distress. For example, among women who had not made positive dietary changes, rating lifestyle as important in preventing recurrence was associated with greater distress, whereas among women who had made a positive change in diet, this belief was associated with less distress.
Conclusions: Results suggest that stronger attributions are associated with greater distress, but engaging in behavior believed to be important in preventing cancer or recurrence may ameliorate this distress.
Key Words: endometrial cancer • cervical cancer • cancer survivors • distress • attributions • health practices
Abbreviations: CAM = complementary and alternative medicine; FACT = Functional Assessment of Cancer Therapy; CES-D = Center for Epidemiological Studies Depression Scale; IES = Impact of Events Scale; CARS = Concerns About Recurrence Scale; ANOVA = analysis of variance; ANCOVA = analysis of covariance.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONNOTESREFERENCES |
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Among individuals with cancer, patients’ beliefs about the causes of cancer differ to some extent by type of cancer. Causal attributions are well-documented for patients with lung and breast cancer and appear to be important to patients in the acute stages of cancer as well as to long-term survivors. Patients with lung cancer frequently cite smoking, followed by toxins or pollution, as causes of their cancer (3,4,7). Breast cancer survivors in two studies have attributed breast cancer to stress, environmental factors, and genetics or heredity (1,2).
Few studies have examined causal attributions among women with gynecologic cancers. In two studies of this population, patients were much less likely than patients with breast and lung cancer to cite specific causes, and much more likely to cite chance or God’s will. In one study, patients with gynecologic cancer and their partners had difficulty generating any causes for the patient’s cancer, and when they did, chance was the most common attribution. In the same study, patients with early-stage cancer were also likely to attribute cancer to their past behavior and patients with advanced-stage cancer to God’s will (5). In this study, women selected causal factors from a small number of broad categories, and therefore results may not capture the full picture of gynecologic cancer patients’ attributions. A sample of Hindu women from India who had cervical cancer had more definite ideas about the causes of their cancer, but were similarly likely to attribute cancer to God’s will, as well as to fate and karma (8). However, results of this study may not generalize to Western women with gynecologic cancer; the authors note that the causal attributions of Indian women are likely more "metaphysical" than illness attributions of Western individuals.
Some researchers have expanded on the study of causal attributions to examine patients’ personal theories about how to control cancer or prevent recurrence. In general, patients believe that healthy behavior, stress reduction, and having a positive attitude are important. Patients with lung cancer most frequently identified behavioral strategies such as diet, exercise, relaxation, and quitting smoking as important in controlling their disease, but they also cited cognitive strategies such as prayer, positive thinking, and acceptance (3). Long-term breast cancer survivors were most likely to cite having a positive attitude as preventing recurrence, followed by health practices including a good diet, exercise, and stress reduction (2).
As suggested by Leventhal’s self-regulation theory, causal attributions have been associated with behavioral responses among patients with cancer. Consistent with the literature suggesting that perceived control among patients with cancer is associated with proactive coping behavior (18,19), findings have indicated that patients with cancer and survivors who attribute their cancer to more controllable causes are more likely to engage in adaptive coping responses or positive health practices. For example, patients with breast cancer who perceived cancer causes to be controllable were more likely to seek information (6) and to modify their health behavior (20) than were patients who perceived causes as less controllable. Patients with head and neck cancer who attributed their cancer to substance abuse and perceived high control over their cancer were less likely to smoke, whereas those who perceived low control were more likely to smoke (21). Similarly, cancer survivors who believed that health behaviors were important in preventing recurrence were more likely to practice them; breast cancer survivors who believed diet or complementary and alternative medicine (CAM) use could prevent recurrence were more likely to take vitamins and dietary supplements and use CAM (2).
Several studies have also examined relationships between causal attributions and psychological adjustment. Although one study found that causal attributions were unrelated to adjustment among patients with gynecologic cancer (5), most evidence indicates that stronger or more elaborated causal attributions are associated with poorer adjustment and greater distress, regardless of the type of attribution (3,17). Psychosocial attributions in particular are related to greater distress and poorer adjustment (4,8).
Forming attributions about cancer appears to be a double-edged sword. On one hand, attributions seem to promote proactive coping behavior, including positive health behavior. On the other hand, individuals who have more or stronger attributions report greater distress and poorer adjustment. This pattern is even more perplexing when one considers the research literature suggesting that active coping is associated with better adjustment among patients with cancer. For example, among gynecologic cancer survivors, active coping is associated with better social well-being and less distress (22). A potential solution to this paradox involves considering the relationship between causal attributions and distress in the context of behavior. Specifically, individuals who continue to engage in behaviors they believe to have caused their cancer may remain distressed. Conversely, individuals who make changes in behavior to which they attribute their cancer may be more likely to be well-adjusted. The current study tested this hypothesis in a sample of long-term gynecologic cancer survivors.
In the current study, we pursued three main objectives. First, we examined beliefs of long-term gynecologic cancer survivors regarding factors that may have played a role in the development of their cancer as well as factors that may currently contribute to preventing a cancer recurrence. We used a structured measure listing a larger number of more specific attributions than has been used in previous studies of patients with gynecologic cancer and asked patients to rate the importance of each factor in causing their cancer. It was predicted that this structured format would allow for a more elaborate picture of gynecologic cancer survivors’ cancer attributions than has been previously found, but we also hypothesized that factors such as chance and God’s will would be endorsed as important by participants in the current study as they have been in past work (5,8). To our knowledge, gynecologic cancer survivors’ theories regarding what may prevent a cancer recurrence have not been examined.
A second objective of the current study was to examine relationships between cancer attributions and both psychological distress and health practices. Although a previous study of patients with gynecologic cancer found no relationship between attributions and adjustment (5), the majority of the literature supports our hypothesis that stronger causal attributions would be associated with greater distress, including greater depressive symptomatology, intrusive thoughts, and cancer-related worry. Relationships between causal attributions and health behavior have not been examined among patients with gynecologic cancer, but given the literature indicating that causal attributions are often associated with proactive behavior including positive health practices, it was hypothesized that the same would be true in our sample. More specifically, we expected that long-term gynecologic cancer survivors who had made positive changes in diet or exercise since diagnosis or were currently practicing healthy behaviors, including receiving regular cancer screenings and avoiding smoking, would be more likely to cite controllable factors as causes of their cancer as compared with women with poorer health practices. Similarly, we predicted that citing controllable factors as important in preventing a recurrence would be associated with positive health practices.
Our final objective was to examine whether interactions between attributions and health behavior predicted distress among gynecologic cancer survivors. We hypothesized that women whose behaviors reflected their attributions regarding cancer prevention or recurrence would report less depression and cancer-related anxiety, whereas women whose behavior did not reflect their attributions would experience more distress. This hypothesis was tested for attributions and health behavior changes related to diet and exercise. For example, it was predicted that women who believe that an unhealthy diet played an important role in causing their cancer or that a good diet may prevent a cancer recurrence and who have improved their diet would report less distress than women with the same belief who have not made positive dietary changes since their diagnosis.
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONNOTESREFERENCES |
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At the time of participation in the study, women ranged from 23 to 90 years of age with a mean age of 60 years. Participants were largely white (95%) and approximately half were married (51%). Thirteen percent had less than 12 years of education, 40% were high school graduates, 27% had some postsecondary education, and 21% had college or postgraduate degrees. Approximately half of the women (47%) were employed full- or part-time at the time of the study.
Women had been diagnosed with cancer between 5 and 20 years before their participation in the current study; on average, participants were 11.2 years postdiagnosis (standard deviation = 3.9). Seventy-four (55%) had been treated for cervical cancer and 60 (45%) had been treated for endometrial cancer. Most participants had received an initial diagnosis of stage I cancer (76%), whereas 11% had been treated for stage II, 6% for stage III, and 4% for stage IV cancer (stage was unknown or unspecified for 3% of the sample). Most women were treated with surgery (87%). Many women had also received radiation therapy (44%) and chemotherapy (25%).
Measures
Demographic and Medical Data
Basic demographic data, including age, ethnicity, marital status, employment status, and education level, were collected from all participants. Information regarding cancer stage and diagnosis was abstracted from medical records and the oncology registry database.
Physical Well-Being
The seven-item physical well-being subscale from the Functional Assessment of Cancer Therapy (FACT) version 3 (23) was used in the current study. Cancer survivors rated statements regarding their physical well-being on a five-point scale based on how true each statement has been for them over the past week. The physical well-being subscale demonstrated adequate internal consistency in the current sample; Cronbach’s alpha was 0.78. The FACT has been shown to discriminate among patients with cancer with different stages of disease and performance abilities (23,24).
Cancer Attributions
Participants rated the importance of a variety of factors in causing their cancer and preventing a cancer recurrence. Participants were instructed as follows: "Sometimes people have ideas about factors that played a role in the development of their cancer. Please rate how important you believe each of the following factors were in the development of your cancer." Participants rated each attribution on a five-point scale from not at all important to very important. Participants then were instructed: "Sometimes people have ideas about what prevents the recurrence of their cancer. Please rate how important each of the following factors are in preventing your cancer from recurring." Ratings were made on the same five-point scale. Items were chosen from previous studies that examined cancer survivors’ beliefs about a variety of potential causal factors and factors that may prevent recurrence (1–3) and included known risk factors for gynecologic cancers (25,26). A list is shown in Table 1. Reliable factors did not emerge, and therefore items were analyzed separately.
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Health Behaviors
Participants completed questions regarding diet, exercise, smoking, and cancer screenings. Participants were asked how often they exercised, smoked, received mammograms and Pap smears, and "tried to prepare healthful meals and snacks" with response options indicating various frequencies appropriate to the behavior in question. Next, women reported whether the frequency with which they exercised, smoked, or tried to prepare healthful meals and snacks had "increased," "stayed the same," or "decreased" since their cancer diagnosis. In the current study, participants’ reports of changes in behaviors since diagnosis was the outcome of interest for diet and exercise; responses to frequency questions were not examined. In statistical analyses, responses were dichotomized for each behavior based on whether women indicated making a positive change in the health behavior or not (i.e., those who reported increasing the frequency with which they exercised/ate healthfully versus those who reported no change or a decrease in exercise/healthful eating). Because only 13 participants indicated that they had changed their smoking habits since diagnosis, current smokers were compared with current nonsmokers. Finally, those who reported receiving cancer screenings at recommended intervals (e.g., annual mammograms) were compared with those who reported less frequent or no screenings.
Depressive Symptoms
The Center for Epidemiological Studies Depression Scale (CES-D) consists of 20 items designed to assess depressive symptomatology. Participants rated how often they experienced each symptom over the past week on a four-point scale (28). The CES-D demonstrated adequate internal consistency in the current sample; Cronbach’s 
= 0.87. The scale has demonstrated good construct validity; the measure has discriminated between psychiatric inpatients and the general population and has shown high correlations with negative life events and other measures of depression (27,28).
Stress-Related Anxiety
The Impact of Events Scale (IES) assesses two dimensions derived by factor analysis: intrusive thoughts or rumination and attempts to consciously avoid such thoughts (28a). The eight-item intrusive thoughts subscale was of interest in the current study. Participants were asked to rate frequency of intrusive thoughts about cancer over the past week on a four-point scale. The intrusion subscale of the IES had adequate reliability; Cronbach’s = 0.91 in the current sample. It is correlated with measures of posttraumatic stress disorder (28b) and has successfully been used to assess anxiety among breast cancer survivors (29,30).
Cancer-Related Worry
The Concerns About Recurrence Scale (CARS; 31) was used to assess worry about cancer recurrence. The CARS consists of two sections; the first section measures overall fear of recurrence and the second measures content of fears. Only the overall fear of recurrence section was used in the current study. Women were asked to rate the frequency, potential for upset, consistency, and intensity of their worry about cancer recurrence on a six-point scale. This four-item scale demonstrated good internal consistency in the current sample; Cronbach’s = 0.87. It has demonstrated correlations with measures of intrusion, avoidance, distress, and well-being among breast cancer survivors (31).
Analyses
Means and standard deviations of importance ratings for each causal and recurrence prevention attribution were calculated. Analysis of variance (ANOVA) was used to compare cervical and endometrial cancer patients’ ratings.
Relationships between attributions and both distress and health behavior were also examined. Potential covariates, including age, cancer site, stage, treatment received, years since diagnosis, current physical well-being, and education, were tested to determine relationships with outcome variables, including three continuous measures of distress and five dichotomous health behaviors. Results indicated that age was significantly related to worry about recurrence (r = –0.19, p = .03), smoking status (F [1, 132] = 9.88, p = .002), and obtaining Pap tests (F [1, 132] = 5.68, p = .02); younger participants were more likely to smoke and to obtain regular Pap smears. Cancer site was related to worry about recurrence (F [1, 132] = 4.10, p = .045) and smoking status (
2 = 8.33, p = .004); cervical cancer survivors reported more worry and were more likely to smoke than were endometrial cancer survivors. Finally, physical well-being was associated with depression (r = –0.51, p < .001). None of the other variables tested were significantly related to distress or health behavior outcomes. For consistency, all subsequent analyses therefore adjusted for age, cancer site, and current physical well-being. Partial correlations adjusting for these variables were used to examine relationships between cancer attributions and measures of distress including CARS, CES-D, and IES intrusion scores. Analysis of covariance (ANCOVA) covarying for the same control variables was used to determine whether attributions differed between individuals who were practicing healthy behaviors versus those who were not (smoking, cancer screenings), as well as between individuals who had made positive changes in diet and exercise versus those who had not.
Hierarchical linear regression analyses were performed to test whether interactions between cancer attributions and health behavior changes predicted anxiety and depression symptomatology as assessed by CES-D and IES intrusion scores. The interactions tested between causal attributions and health behavior changes were as follows: diet attribution and dietary change, lifestyle attribution and dietary change, and lifestyle attribution and exercise change. The same combinations were also tested for recurrence prevention attributions, with the addition of the interaction between exercise attribution and exercise change. Smoking changes were not examined as an outcome for tobacco attributions because only 13 people changed smoking status since their cancer diagnosis. Each interaction term was computed with centered variables (32). For each model tested, control variables (age, cancer site, and physical well-being) were entered in the first block, the health behavior change and cancer attribution being tested were entered in the second block, and the interaction term was entered in the final block. All analyses were repeated for both the dependent variable of CES-D and the dependent variable of IES intrusion. A significant interaction was followed up by substituting attribution scores 1 standard deviation above and below the mean for each group (those who had made a positive change versus those who did not) into the regression equation and plotting regression lines to examine the sources of the interaction (32).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONNOTESREFERENCES |
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Cancer Beliefs and Distress
Partial correlations between causal attributions and distress are shown in Table 2, and partial correlations between factors believed to prevent a cancer recurrence and distress are illustrated in Table 3. After controlling for age, type of cancer, and physical status, attributing cancer to almost any factor was associated with greater depressive symptomatology, intrusive thoughts, and recurrence worry. Exceptions included attributing cancer to God’s will or chance. In contrast, believing that a variety of factors may prevent a cancer recurrence was generally unrelated to distress. However, believing that diet, exercise, or medication is important in preventing recurrence was associated with greater intrusion and recurrence worry.
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Cancer Beliefs and Health Behavior
Survivors who made positive changes in their diet since diagnosis were significantly more likely to attribute cancer to stress (F [1, 129] = 4.02, p = .047) and environmental toxins (F [1, 129] = 5.68, p = .02) than were survivors who had not made positive dietary changes. However, they were no more likely to attribute cancer to diet or to an unhealthy lifestyle. They were more likely to believe that diet (F [1, 129] = 7.47, p = .01), exercise (F [1, 129] = 4.27, p = .04), and stress reduction (F [1, 129] = 6.95, p = .01) could prevent a cancer recurrence.
Survivors who increased the amount of exercise they did were significantly less likely to attribute cancer to God’s will (F [1, 129] = 4.37, p = .04) and injury (F [1, 129] = 4.27, p = .04) than those who did not increase exercise since diagnosis. They were no more likely to attribute cancer to an unhealthy lifestyle or to believe that exercise or a healthy lifestyle could prevent a cancer recurrence.
There were no significant differences between smokers and nonsmokers in attributing cancer to tobacco use or to an unhealthy lifestyle. Nonsmokers were significantly more likely than smokers to believe that medical checkups/screenings (F [1, 129] = 4.02, p = .047), stress reduction (F [1, 129] = 4.18, p = .04), and a healthy lifestyle (F [1, 129] = 7.63, p = .01) could prevent recurrence.
Survivors who obtained regular Pap smears were significantly more likely to attribute cancer to environmental toxins (F [1, 129] = 4.61, p = .03) and showed a trend toward attributing cancer to lifestyle (F [1, 129] = 3.56, p = .06) as compared with those who did not get regular Pap tests. They were also more likely to believe that medical checkups/screenings (F [1, 129] = 11.74, p < .01), diet (F [1, 129] = 5.31, p = .02), and exercise (F [1, 129] = 3.96, p = .049) could prevent a cancer recurrence.
Survivors who obtained regular mammograms showed a trend toward attributing cancer to environmental toxins (F [1, 129] = 3.57, p = .06) as compared with those who did not get regular mammograms. They were significantly more likely to believe that diet (F [1, 129] = 5.10, p = .03) and exercise (F [1, 129] = 9.78, p < .01) could prevent a cancer recurrence and marginally more likely to believe that medical checkups/screenings (F [1, 129] = 3.50, p = .06) and stress reduction (F [1, 129] = 3.53, p = .06) could prevent a recurrence.
Cancer Beliefs, Health Behavior Change, and Distress
Cancer cause and recurrence prevention attributions interacted with health behavior changes to predict intrusive thoughts and depressive symptomatology in several instances. Attributing cancer to diet interacted with change in diet to predict intrusive thoughts (ß = 0.23, p = .02) and depression, (ß = 0.22, p = .01). Plots substituting dietary attribution importance scores 1 standard deviation above and below the mean score for each group (those who did and did not make positive dietary changes) into the regression equations were examined. Plots indicated that among those who had not made positive dietary changes, believing that diet was important in the development of one’s cancer was associated with greater distress, but there was no relationship between a diet attribution and distress among women who had made positive dietary changes (see Figure 1).
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Attributing cancer to an unhealthy lifestyle also interacted with change in diet to predict intrusive thoughts (ß = 0.20, p = .048) and depressive symptoms (ß = 0.20, p = .03). Plots of the data indicated that among those who had not made positive dietary changes, believing that an unhealthy lifestyle was important in the development of one’s cancer was associated with greater distress, but there was no relationship between a lifestyle attribution and distress among women who had made positive dietary changes (see Figure 2).
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Attributing cancer to an unhealthy lifestyle interacted with change in exercise to predict intrusion (ß = 0.25, p = .04) but not depression (ß = 0.13, p = .23). Plots showed that among those who had not increased exercise, believing that an unhealthy lifestyle was important in the development of one’s cancer was associated with greater anxiety. In contrast, a lifestyle attribution was associated with less anxiety among women who had increased exercise (see Figure 3).
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Believing that a healthy lifestyle is important in preventing recurrence interacted with change in diet to predict intrusion (ß = 0.30, p = .004) and depression (ß = 0.21, p = .02). Plots indicated that among those who had not made positive dietary changes, this attribution was associated with greater distress. In contrast, this belief was associated with less distress among women who had made positive dietary changes (see Figure 4). However, there was no interaction between the belief that lifestyle may prevent recurrence and change in exercise in predicting depression or intrusive thoughts.
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There were no significant interactions between the beliefs that diet and exercise can prevent recurrence and changes in diet and exercise.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONNOTESREFERENCES |
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Cancer survivors’ theories about what caused their cancer were not necessarily consistent with current scientific knowledge. Genetics/heredity was rated as the most important cancer cause and hormonal factors were ranked fourth; both are known to be associated with the development of gynecologic cancers (25,26). However, lifestyle factors, diet, and tobacco use were not perceived by the majority of survivors to be important causal factors. In contrast to participants’ personal theories, obesity and a high-fat diet are associated with increased risk for endometrial cancer, whereas physical activity may be protective (26). Additionally, smoking, early intercourse, and multiple sexual partners are risk factors for cervical cancer, whereas a healthy diet including vitamins A and C may be protective (25). Gynecologic cancer survivors believed that stress played a more important role in the development of their cancer than did these known risk factors; stress ranked second in average ratings of importance with 46% of women rating stress as somewhat to very important in the development of their cancer. Although this notion is relatively popular, the literature regarding links between stress and the development of cancer is inconclusive, with some positive (33,34) and some null findings (35,36). Recent reviews and meta-analyses have concluded that there is no convincing overall link between stressful life events and cancer risk (37–39). It may be that stressful life events close in proximity to a cancer diagnosis are more salient to women than their health practices or other risk factors.
Gynecologic cancer survivors also had definite ideas regarding what they could do to prevent a cancer recurrence. After medical checkups and screenings, factors such as positive attitude and prayer were rated as most important in preventing recurrence. Factors known to be associated with reduced risk for gynecologic cancers, including a healthy lifestyle, diet, and exercise (25,26), fell toward the middle of the list, as did stress reduction. God’s will and chance were not considered to be nearly as important as other factors in preventing a cancer recurrence with both falling toward the end of the list of potential factors. There were no significant differences between cervical and endometrial cancer survivors’ attributions. Perhaps the most interesting finding was that 94% of participants believed that a positive attitude was somewhat to very important in preventing a cancer recurrence. As is the case with the role of stress in the development of cancer, the literature is far from conclusive regarding the effects of a positive attitude on cancer recurrence. There is some evidence that pessimism or hopelessness is associated with recurrence and poorer survival (40–42), whereas having a "fighting spirit" is associated with reduced risk of recurrence and better survival (43,44), but there are just as many studies that have not found these links (45–48). Moreover, some research has shown that putting on a happy face could actually be detrimental; suppression of negative emotions has been associated with poorer prognoses among patients with cancer, whereas expression of emotions has been associated with better outcomes (49–52). Popular media promoting the significance of mental attitude in overcoming disease or encouragement from family and friends to maintain a "positive attitude" may explain participants’ beliefs.
Although gynecologic cancer survivor’s beliefs about cancer cause and recurrence prevention were not necessarily consistent with medical knowledge, they were very similar to attributions made by breast cancer survivors (1,2). Both groups cite stress and genetics as important causal factors and having a positive attitude as particularly important in preventing a recurrence. In contrast, patients with lung cancer are more likely to attribute their cancer to poor health behaviors (3,4,7), perhaps as a result of common knowledge of links between behavioral factors and lung cancer. It may be that patients who have cancers in which the causes are less clear are more likely to attribute cancer to psychosocial factors such as stress and mental attitude. Nonetheless, even patients with lung cancer cited a positive attitude as important in preventing a recurrence (3). It appears that cancer patients’ common-sense beliefs about their disease generalize to some extent across cancer site, and psychological factors are widely believed to play a role in cancer development and course.
In general, women had much stronger ideas regarding factors that may prevent a cancer recurrence than about what may have caused their cancer. Most of the factors we asked about were rated as somewhat to very important in preventing a cancer recurrence by the majority of women, whereas generally around one third of participants rated specific causal factors as somewhat to very important in the development of their cancer. Because cancer diagnosis and treatment occurred 5 or more years before the study, making attributions for the cause of one’s cancer may not be as important as thinking about what can now be done to prevent a cancer recurrence. This pattern may also be psychologically protective; believing that almost any factor played an important role in the development of one’s cancer was associated with elevated depressive symptomatology and anxiety, whereas beliefs about what prevents cancer recurrence were generally unrelated to distress.
Findings are largely consistent with the literature indicating that stronger or more elaborated causal attributions are associated with greater distress among patients with cancer (3,4,17). The exception was the finding that attributing cancer to uncontrollable factors such as God’s will or chance was generally unrelated to distress. This pattern of findings stands in contrast to literature suggesting that greater perceived control is associated with less distress and better psychological adjustment among patients with cancer (1,53,54). It is possible that survivors who perceive they could have somehow prevented their cancer are more distressed. Given that the current study is cross-sectional and direction of causality cannot be determined, it is also plausible that women who are more distressed spend more time thinking or ruminating about the causes of their cancer. As previously described, having strong ideas about what prevents cancer recurrence was generally unrelated to distress. Exceptions were beliefs that health behaviors such as diet or exercise may prevent recurrence; these beliefs were associated with greater anxiety. Perhaps believing that one’s own health behavior determines cancer recurrence is anxiety-provoking because survivors with this belief feel a greater sense of personal responsibility for their health.
Compared with women who had not made positive health behavior changes or were not currently practicing healthy behaviors, women who had made positive health behavior changes and obtained regular cancer screenings generally attributed cancer to controllable causes (stress, unhealthy lifestyle) or environmental toxins. The double-edged sword was evident in the current study, however; as previously noted, causal attributions regarding stress, environmental toxins, and lifestyle were also associated with greater depression, intrusion, and recurrence worry. Women who had made positive health behavior changes and obtained regular cancer screenings were also more likely to believe that exercise, diet, stress reduction, and medical screenings could prevent a recurrence. The beliefs that diet and exercise may prevent a recurrence appear to be adaptive with respect to health behavior but were also associated with increased anxiety, another example of the double-edged sword.
The interactions between attributions and health practices in predicting depressive and anxious symptomatology helps to explain these perplexing relationships by clarifying the nature of the associations between cancer attributions and distress. Consistent with initial hypotheses, believing that diet or an unhealthy lifestyle caused one’s cancer or that a healthy lifestyle can prevent cancer recurrence was associated with greater depression and anxiety only among women who had not made positive changes in their diet and exercise patterns since their diagnosis. In contrast, among women who had made positive changes in these health behaviors, these beliefs were unrelated to distress or were associated with fewer symptoms of anxiety and depression. Therefore, the relationship between attributing cancer to controllable factors and greater distress appears to be present only among individuals who continue to engage in behaviors they believe may have caused their cancer.
There are several limitations of the current study. As previously mentioned, the cross-sectional design of the current study precludes any firm conclusions regarding directions of causality. Also, participants were long-term survivors who had been diagnosed with cancer 5 or more years previously. It is possible that patients with gynecologic cancer undergoing treatment or closer in time to diagnosis would have different causal attributions and ideas about recurrence prevention. Nonetheless, it is interesting to note that long-term cancer survivors still have fairly strong ideas about what may have caused their cancer and have particularly strong ideas about how they may continue to prevent a cancer recurrence.
Despite these limitations, the current study has elaborated the previously incomplete picture of gynecologic cancer survivors’ personal theories about their disease, indicating that their causal attributions are not necessarily consistent with current medical knowledge of gynecologic cancers. Therefore, it may be useful for healthcare professionals to ask patients about their personal beliefs, given that these beliefs are associated with compliance with recommended health practices as well as with psychological distress. This is the first study to our knowledge to examine interactions between attributions and behavior in predicting distress among patients with cancer, and findings bring together initially perplexing patterns of evidence from studies that have examined either psychological or behavioral correlates of attributions. Our data suggest that cancer attributions involving personal control may be associated with greater distress, but engaging in behavior believed to be important in preventing cancer or recurrence appears to ameliorate this distress.
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NOTES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONNOTESREFERENCES |
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Received for publication October 26, 2004; revision received May 23, 2005.
DOI:10.1097/01.psy.0000188402.95398.c0
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