Coping styles as predictors of survival time in bladder cancer

doi:10.4236/health.2010.25064

Paper Menu >>

Journal Menu >>

Vol.2, No.5, 429-434 (2010)

doi:10.4236/health.2010.25064

Health

Openly accessible at

Coping styles as predictors of survival time in bladder

cancer

Jochen Hardt1*, Rolf Gillitzer2, Susanna Schneider1, Sabine Fischbeck1, Joachim W. Thüroff2

1Department of Medical Psychology and Medical Sociology, University of Mainz, Mainz, Germany; *Corresponding Author:

jochen.hardt@gmx.de

2Clinic for Urology, University of Mainz, Mainz, Germany

Received 2 December 2009; revised 8 January 2010; accepted 15 January 2010.

ABSTRACT

The role of coping in the survival of cancer is a

controversial topic. To specifiy the influence of

coping on survival time, we conducted a longi-

tudinal, prospective and observational study. In

a preoperative interview, 105 patients with pri-

mary bladder cancer were asked about their

active and depressive coping strategies. Ten

years later, the survival rate was recorded; in

cases of death, it was noted whether or not it

was in consequence of the bladder cancer.

Kaplan-Meier analyses of the collected data

revealed a mean survival rate of about 60% after

10 years. Cox regression demonstrated no

significant effect for active or depressive coping

when tumour stage was controlled for. Patients

who presented with high values for either of the

coping strategies lived only slightly longer than

those with low values. Therefore, it can be

concluded that preoperative coping does not

seem to demonstrate an important role for

survival in bladder cancer.

Keywords: Oncology; Coping; Bladder Cancer;

Survival; Longitudinal Study

1. INTRODUCTION

With respect to survival time of patients with cancer, the

role of coping is a controversial topic. Early intervention

studies provided some evidence that active coping and

the development of a fighting spirit against the cancer

were associated with longer survival times [1-3]. In

these studies, a usually randomly selected portion of the

patients received some sort of psychotherapy or psycho-

social support, whereas patients in a control group did

not. Typically, patients who were treated displayed

longer survival times than controls [4]. These studies

have been criticised as having flaws in design and anal-

yses [5]. For example, in the study by Spiegel et al. [6],

the control group showed an unusually strong decline in

survival, i.e. an atypical form for a survival curve. The

intervention group, however, displayed a rather normal

survival curve, as would be expected for the given type

of cancer. Furthermore, the sample sizes in these studies

have been criticised as being small on average-often

fewer than 40 subjects. In 2007, three replication studies

of classical psychosocial interventions were published-

none showing a positive effect on survival time [7].

Most of the survival studies were carried out on patients

with breast cancer, therefore the results might not nece-

ssarily be representative for other types of cancer. A recent

review concluded: “Some researchers view the mind-

cancer survival question as resolved and negative, wher-

eas others identify conceptual and methodological chal-

lenges and view the possible impact of psychosocial

factors on survival as simply unproven” [8].

A study that bolstered the latter supposition demo-

nstrated that giving psychosocial support did lead to

prolonged survival [9] in breast cancer. Additionally, a

further study proved that giving even very limited psy-

chosocial support to patients with gastrointestinal cancer

led to a doubled survival rate after 10 years when com-

pared with controls without psychosocial support [10].

In general, observational studies have added to the

controversy rather than confirming one specific theory.

Similar to intervention studies, observational studies

yielded some evidence for better survival in patients

with active versus depressive coping, but also some evi-

dence that psychosocial factors do not have an effect on

survival rates [2]. These observational studies often suf-

fered from the fact that many variables with a potential

impact on the development of cancer were examined in

small samples. For example, Gruhlke et al. [11] exam-

ined a total of 34 coping strategies in a sample of about

60 patients who were receiving bone marrow transplants.

In a design like this, there is an increased risk of finding

significant predictors even if no associations are actually

J. Hardt et al. / HEALTH 2 (2010) 429-434

430

present. Another study found effects of traumatic stress

experience on survival in breast cancer [12] in addition

to effects of mature and immature defence styles in

various patients with late-stage cancer [13]. Other results

from observational studies appear to be sounder and

could be replicated. In an early study, for example,

slightly higher cancer rates in widowed people than in

the rest of the population were reported [14]. This result

was confirmed later, based on the Danish registries [15].

Faller et al. [16] demonstrated that depressive coping

was associated with significantly shorter survival times

in patients with lung cancer. In this study, various coping

styles were measured in 107 patients before surgery; one

of these styles proved to be associated with survival time

assessed up to 10 years after surgery, i.e. depressive

coping predicted shorter survival. The association

remained significant even after controlling for cancer

staging and the Karnofski performance status. Moreover,

it was found that a majority of patients themselves

believe that stress and emotional problems are associated

with the development of cancer. Active coping did not

predict a better survival, a result that was surprising

because it was a main predictor in other studies [17].

Active and depressive coping differ on account of the

fact that active coping focuses on finding solutions for

the problems directly caused by the stressor itself

whereas depressive coping concentrates on the negative

emotions evoked by the stress. On the other hand, Ake-

chi et al. [18] could not find any psychosocial predictor

for survival time in patients with lung cancer. A study by

Johansen et al. indicated that not even psychosocial dis-

tress was associated with survival in various forms of

cancer [19]. Based on the Danish health registries, the

authors compared the national incidence rate of cancer

with the incidence rate in over 10 000 parents who had

experienced the diagnosis of cancer in their child. The

rationale of this study was that such an experience con-

stitutes an extraordinary stress factor for a parent, and if

psychosocial stress were associated with cancer, this

stress would produce some effects. On finding that both

rates were the same over a period of 50 years for breast

cancer, lymphoma, leukaemia and other tumours, the

authors concluded that psychosocial stress does not play

a role in the incidence of cancer.

The present study was conducted to explore the role

of coping in a rarely examined form of cancer, i.e.

bladder cancer. The estimated yearly incidence rate of

bladder cancer in Germany is about 40 per 100 000 in

men and about 10 per 100 000 in women; in countries

where schistosomiasis occurs, the rate is higher. At

present, non-invasive forms of bladder cancer have been

seen in about 80% of primary diagnoses and have

usually been treated conservatively; invasive forms have

affected about 15% of patients and lead to either bladder

extraction, necessitating an artificial urinary diversion,

or to radiation therapy. Even for invasive bladder cancer,

the prognosis for patients is not bad. Leissner et al. [20]

estimated 10-year survival rates of about 50% after

radical surgery; for patients with low-stage tumours,

survival rates were even better.

2. MATERIALS AND METHODS

2.1. Design

The design of the study was prospective and observ-

ational. In 1999, data collection for a one-year follow-up

study about quality of life after urinary diversion was

finished and data were analysed [21]. At that time, an

article by Faller et al. [16] was published that showed

differences in survival time of lung cancer patients

depending on a preoperative coping strategy. Due to the

fact that 1) the instrument used to assess self-rated cop-

ing was the same in the Faller et al. study and in ours; 2)

the times of assessments were similar; 3) various back-

ground variables were assessed similarly; and 4) the

sample sizes were almost identical, we decided to set up

a 10-year follow-up of our sample in an attempt to

cross-validate the results of Faller et al..

2.2. Subjects

Utilizing a consecutive recruitment strategy, we exa-

mined a total of 108 patients who were treated in the

urological clinic in Mainz between January 1996 and

April 1998 because of a primary bladder tumour. The

patients were examined one to three days preoperatively

by means of an interview and a questionnaire booklet. At

that time, patients believed that their bladder was going

to be removed and replaced by an artificial urinary

diversion. A total of 105 of the patients received an arti-

ficial diversion, in three patients the bladder was retained.

All patients gave written, informed consent to participate

in a study about quality of life. They were informed that

their participation in the study included their willingness

to be contacted one year after surgery and asked to fill

out another questionnaire about quality of life. Three

patients withdrew their participation after surgery, and

no further information was gathered about them. The

remaining 105 patients were contacted one year after

surgery; at this time, 81 patients reported about their

quality of life. One year after surgery, patients showed a

stronger decrease in physical than in mental quality of

life; in addition, there were complex interactions be-

tween coping and quality of life [21]. At that time, 19

patients were deceased; out of the remaining five, three

felt too sick to fill out the questionnaire and two did not

respond to our letters. For the 19 patients who were de-

ceased, we recorded when they had died and whether or

not death was a consequence of the bladder tumour. In

cases of uncertainty regarding the latter point, a urologist

J. Hardt et al. / HEALTH 2 (2010) 429-434

431

was contacted to make a decision.

In 2007, all 81 patients who had responded one year

after surgery, in addition to the five surviving patients

who had failed to respond, were contacted again via a

letter reminding them about their stay at the urological

department of the University of Mainz and their partici-

pation in a study 10 years previously. The letter indi-

cated that in the next few days they would receive a

phone call query regarding their current quality of life.

During the phone call, patients were first asked how they

were coming along with their artificial urinary diversion;

in case of problems, a visit to the urological department

in Mainz was offered. For patients who were interested,

an appointment with a urologist (RG) was set outside the

regular patient schedule. Then, a quality of life ques-

tionnaire was sent to the surviving patients. For deceased

patients, relatives were asked about the time of death and

whether the death was a consequence of the bladder

tumour or of another disease or circumstance. Several

measures were taken to collect information about those

patients who could not be reached in this way. Local

authorities were contacted to find out whether a patient

had moved or died. Those who had moved were con-

tacted again at their new address; for the deceased, the

local registries of death were consulted to find out

whether or not the death was due to the bladder tumour.

When no data were available, patients’ family doctors,

general practitioners, or local urologists were contacted.

2.3. Instruments

Coping was assessed by the Freiburger Fragebogen zur

Krankheitsverarbeitung [FKV-LIS SE: 22], a widely

used questionnaire in Germany. The questionnaire con-

tains 35 items and is designed to measure five dimen-

sions: active coping (5 items), depressive coping (5

items), distraction (5 items), self-affirmation (5 items),

and trivializing (3 items; the remaining 12 items were

not utilzed). Since we were interested only in replicating

the results of Faller et al. [16] and not in undertaking any

exploratory analyses, we considered only two dimen-

sions: active and depressive coping. Neither dimension

represents the end of a continuum; rather, each reflects a

distinctive dimension [22]. The reliabilities of the scales

were moderate within the present sample, i.e. Cron-

bach’s  = 0.72 for active coping and  = 0.69 for de-

press- sive coping. The correlation between the two di-

mensions was slightly positive, i.e. r = 0.27, p < 0.01.

Examples of items for active coping were “gathering

information about the disease and its treatment” and

“deciding to actively fight the disease”. For depressive

coping, examples were “self-pity” and “withdrawal from

others”. A significant background variable that was con-

sidered in the Faller et al. study was tumour stage; hence,

we also included it in our analysis. Tumour stage and

grade were coded according to the TNM classification.

In addition, gender and age at surgery were included.

2.4. Statistics

A few missing data were substituted by the mean or a

value close to the mean (Table 1). This method has been

proven to be superior to analysis of complete data in

various simulation studies and a complex method of

substituting missings such as multiple imputation did not

seem justified given the small amount of missing data in

the present sample. Bivariate associations were calcu-

lated as Pearson correlation coefficients, except for sur-

vival time. Because a substantial proportion of patients

in this sample died from reasons other than bladder can-

cer, multivariate as well as bivariate associations with

survival time were calculated using Cox regressions,

defining death from bladder cancer as the response. This

procedure ensured that patients who were still alive and

those who died due to disorders other than a bladder

tumour were treated appropriately. Survival curves were

presented by Kaplan-Meier estimates. Statistical analy-

ses were performed by R [23].

3. RESULTS

Ten years after surgery, 41 patients were still alive; 46

were deceased due to the tumour progression and 17

patients had died from other diseases. Regarding the

deceased patients, dates of death and information about

the reasons for death were recorded for all 46 patients.

Again, in cases of unclear information, a urologist (RG)

was contacted to decide whether or not the death was

tumour-related. Thus, a total of 105 patients (97% of the

intended sample) were analysed. Additional relevant

patient characteristics are summarised in Table 1.

In the bivariate analysis, there was a significant effect

of active coping (hazard ratio = 0.70, p < 0.05) on sur-

vival in the assumed direction, depressive coping

showed no significant effect (hazard ratio = 0.70, p <

0.14; Figure 1, Table 2). In the multivariate analyses, i.e.

controlling for various confounders, tumour stage (haz-

ard ratio = 1.51, p < 0.01) and age at surgery (hazard

ratio = 1.04, p < 0.05) were the only significant predic-

tors of survival time (Table 3). Active as well as de-

pressive coping became non-significant.

4. DISCUSSION

The present study was designed to replicate a finding of

Faller et al. that depressive coping is associated with

shorter survival time and active coping may be associ-

ated with longer survival time in cancer patients. The

hypothesis for this study was not formulated very spe-

cifically because the Faller et al. study did not prove a

significant effect for active coping. However, the hy-

pothesis had to be rejected for both coping strategies.

Controlling for confounders moved all effects for either

J. Hardt et al. / HEALTH 2 (2010) 429-434

432

Table 1. Description of variables.

Variable possible range Valid N Min Max Mean Standard

deviation

Missings

substituted by

Y Survival time (years) 0-11 105 0.01 11.17 5.98 4.19 -

A Active coping (FKV) 0-5 104 1.00 3.20 3.36 0.88 3.36

D Depressive coping

(

FKV

)

0-5 104 1.00 5.00 1.82 0.64 1.82

S Tumour stage 0-4 101 0.00 4.00 2.15 1.23 2

G Tumour grade 0-4 105 0.00 4.00 2.36 1.07 2

E Age at surgery 18-90 105 41.77 82.53 64.42 8.93 -

X Sex 105 0

female

male

75%

male

- -

Table 2. Bivariate associations.

Variable Survival time* Active Depressive Stage Grade Age

Survival time

Active coping 0.69 (0.12)

p < 0.035

Depressive coping 0.70 (0.17)

p < 0.136

0.27

0.005

Tumour stage 1.52 (0.20)

p < 0.002

–0.30

0.002

–0.16

0.096

Tumour grade 1.07 (0.15)

p < 0.647

–0.02

0.814

0.03

0.760

0.44

0.000

Age at surgery 1.04 (0.22)

p < 0.029

–0.16

0.106

–0.37

0.000

0.03

0.729

–0.03

0.783

Sex 1.50 (0.56)

p < 0.274

0.07

0.474

–0.11

0.281

–0.05

0.579

0.07

0.472

0.34

0.000

* Hazard ratio (std err), all others Pearson correlations and p-values.

Table 3. Prediction of survival time.

Response variable: Y, survival time

Starting model Selected model Excluded variables

Explanatory variable Estim. coeff. Stand. error z-value Estim. coeff.Stand. errorz-value z-value

Active coping –0.18 0.20 0.93 –0.27 0.10 –2.67 -

Depressive coping 0.01 0.27 0.05 - - -

Tumour stage 0.41 0.15 2.70 0.41 0.13 3.07

Tumour grade –0.11 0.17 –0.63 - - -

Age 0.03 0.02 1.62 0.04 0.02 2.09

Sex 0.25 0.40 0.63 - - -

Total model Chi² (2) = 14.12, p < 0.001

J. Hardt et al. / HEALTH 2 (2010) 429-434

433

Openly accessible at

Figure 1. Kaplan-Meier estimates for survival as a function of

active and depressive coping.

of the coping strategies well into the range of random

variation.

When interpreting these results, it should be taken into

consideration that our study focused on a rarely examind

form of cancer, i.e. bladder cancer. Well-identified risk

factors for bladder cancer are chemicals used in the rub-

ber industry, smoking, and the use of certain drugs [24].

The Faller et al. study dealt with lung cancer and the

Küchler et al. [10] study with gastrointestinal cancers;

most other research concerning psychosocial risk factors

has dealt with breast cancer. A possible explanation for

the disparity of the results is that different forms of can-

cer may have different origins; it is possible that only

some forms are associated with psychosocial factors. An

alternative explanation takes unhealthy patient habits or

behaviour into consideration, e.g. smoking in the case of

lung cancer. Smoking is not only a risk factor for the

development of lung cancer, continued smoking also

contributes to a poor prognosis for those who have

already developed cancer. It is possible that depressive

coping is associated with more smoking than active

coping, a theory that may explain the association observed

in the Faller et al. study. Even though smoking is also

discussed as a risk factor in bladder cancer, the associa-

tion is weaker and probably works over a longer time

period. So far, no unhealthy patient behaviour has been

directly associated with bladder cancer.

The present study has the following limitations. 1)

Bladder cancer has typically been present for at least 10

years when it is diagnosed. In patients who have severe

bladder cancer, such as those in our study, it is probably

longer-established for the majority of patients. Hence, a

study beginning observation at the time of surgery relies

on left-truncated data [25]. For this reason, it is possible

that the time period during which psychosocial variables

could have influenced the genesis of bladder cancer was

not captured by our time of observation; 2) A sample

size of about 100 may be too small to detect an effect; 3)

Controlling all relevant confounders, for example smok-

ing, was not possible in this study.

Given these limitations, the present study demonstrates

an absence of any psychosocial effect on the course of

cancer rather than support for a positive effect. It was

active coping that was predictive in our unadjusted anal-

ysis rather than depressive coping as in the Faller et al.

study. In addition, the effect of depressive coping tended

towards a counterintuitive direction, despite its being

non-significant. It is either possible that the effects of

coping on survival in bladder cancer are small, or that

there is no effect. This finding applies to a form of

cancer that has not been studied before in this respect.

Hence, further investigations are needed.

REFERENCES

[1] Spiegel, D. (1997) Psychosocial aspects of breast cancer

treatment. Seminars in Oncology, 24, 36-47.

[2] Petticrew, M., Bell, R. and Hunter, D. (2002) Influence

of psychological coping on survival and recurrence in

people with cancer: Systematic review. British Medical

Journal, 325, 1066-1075.

[3] Fawzy, F.I., Fawzy, N.W., Hyun, C.S., Elashoff, R.,

Guthrie, D., Fahey, J.L. and Morton, D.L. (1993) Malig-

nant melanoma. Effects of an early structured psychiatric

intervention, coping, and affective state on recurrence

and survival 6 years later. Archives of General Psychiatry,

50(9), 681-689.

[4] Blake-Mortimer, J., Gore-Felton, C., Turner-Cobb, J.M.

and Spiegel, D. (1999) Improving the quality and quan-

tity of life among patients with cancer: A review of the

effectiveness of group psychotherapy. European Journal

of Cancer, 35(11), 1581-1586.

[5] Fox, B.H. (1998) A Hypothesis about Spiegel et al.’s

1989 paper on psychosocial intervention and breast can-

cer survival. Psycho-Oncology, 7, 361-370.

[6] Spiegel, D., Bloom, J.R., Kraemer, H.C. and Gottheil, E.

(1989) Effect of psychosocial treatment on survival of

patients with metastatic breast cancer. Lancet, 2, 888-

891.

[7] Boesen, C. and Johansen, C. (2008) Impact of psycho-

therapy on cancer survival: Time to move on? Current

Opinion in Oncology, 20(4), 372-377.

[8] Stephen, J.E., Rahn, M., Verhoef, M. and Leis, A. (2007)

What is the state of the evidence on the mind-cancer sur-

vival question, and where do we go from here? A point of

view. Support Care Cancer, 15(8), 923-930.

[9] Andersen, B.L., Yang, H.C., Farrar, W.B., Golden-Kreutz,

D.M., Emery, C.F., Thornton, L.M., Young, D.C. and

Carson, W.E., 3rd (2008) Psychologic intervention im-

proves survival for breast cancer patients: A randomized

clinical trial. Cancer, 113(12), 3450-3458.

J. Hardt et al. / HEALTH 2 (2010) 429-434

434

[10] Kuchler, T., Bestmann, B., Rappat, S., Henne-Bruns, D.

and Wood-Dauphinee, S. (2007) Impact of psychothera-

peutic support for patients with gastrointestinal cancer

undergoing surgery: 10-year survival results of a ran-

domized trial. Journal of Clinical Oncology, 25, 2702-

2708.

[11] Grulke, N., Bailer, H., Hertenstein, B., Kachele, H., Ar-

nold, R., Tschuschke, V. and Heimpel, H. (2005) Coping

and survival in patients with leukemia undergoing al-

logeneic bone marrow transplantation—long-term fol-

low-up of a prospective study. Journal of Psychosomatic

Research, 59(5), 337-346.

[12] Palesh, O., Butler, L.D., Koopman, C., Giese-Davis, J.,

Carlson, R. and Spiegel, D. (2007) Stress history and

breast cancer recurrence. Journal of Psychosomatic Re-

search, 63(3), 233-239.

[13] Beresford, T.P., Alfers, J., Mangum, L., Clapp, L. and

Martin, B. (2006) Cancer survival probability as a func-

tion of ego defense (adaptive) mechanisms versus de-

pressive symptoms. Psychosomatics, 47, 247-253.

[14] Jones, D., Goldblatt, P.O. and Leon, D.A. (1984) Be-

reavement and cancer: Some results using data on deaths

of spouses from the OPCD longitudinal study. British

Medical Journal, 284, 461-464.

[15] Johansen, C., Schou, G., Soll-Johanning, H., Mellem-

gaard, A. and Lynge, E. (1998) Marital status and sur-

vival in colorectal cancer. Ugeskr Laeger, 160(5), 635-

638.

[16] Faller, H., Bülzebruck, H., Drings, P. and Lang, H. (1999)

Coping, distress, and survival among patients with lung

cancer. Archives of General Psychiatry, 56, 756-762.

[17] Riehl-Emde, A., Buddeberg, C., Muthny, F.A., Landolt-

Ritter, C., Steiner, R. and Richter, D. (1989) Causal attri-

buation and coping with the disease in breast cancer pa-

tients. Psychother Psychological Medicine, 39, 232-238.

[18] Akechi, T., Okamura, H., Okuyama, T., Furukawa, T.A.,

Nishiwaki, Y. and Uchitomi, Y. (2009) Psychosocial fac-

tors and survival after diagnosis of inoperable non-small

cell lung cancer. Psychooncology, 18(1), 23-29.

[19] Johansen, C. and Olsen, J.H. (1997) Psychosocial stress,

cancer incidence and mortality from non-malignant dis-

eases. British Journal of Cancer, 75(1), 144-148.

[20] Leissner, J., Hohenfellner, R., Thüroff, J.W. and Wolf,

H.K. (2000) Lymphadenektomie in patients with transi-

tional cell carcinoma of the urinary bladder: Significance

for staging and prognosis. BMU Int, 85, 817-823.

[21] Hardt, J., Petrak, F., Filipas, D. and Egle, U.T. (2004)

Adaptation to life after surgical removal of the bladder—

an application of Graphical Markov Models for analysing

longitudinal data. Statistics in Medicine, 23, 649-666.

[22] Muthny, F.A. and Koch, U. (1998) Spezifität der Krank-

heitsverarbeitung bei Krebs. In: Koch, U. and Weis, J.,

Eds., Krankheitsbewältigung bei Krebs und Möglich-

keiten der Unterstützung, Stuttgart, Schattauer, 49-58.

[23] R Development Core Team: R: A language and environ-

ment for statistical computing. Vienna, R Foundation for

Statistical Computing, 2007.

[24] Golka, K., Goebell, P.J. and Rettenmeier, A.W. (2007)

Ätiologie und Prävention des Harnblasenkarzinoms.

Deutsches Ärzteblatt, 104, 719-723.

[25] Wolfson, C., Wolfson, D.B., Ashgarian, M., M'lan, C.E.,

Ostby, T., Rockwood, K. and Hogan, D.B. (2001) A re-

evaluation of the duration of survival after the onset of

dementia. New England Journal of Medicine, 344(15),

1111-1116.