Vol.2, No.5, 429-434 (2010)
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Coping styles as predictors of survival time in bladder
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:
2Clinic for Urology, University of Mainz, Mainz, Germany
Received 2 December 2009; revised 8 January 2010; accepted 15 January 2010.
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
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
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
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.
2.1. 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
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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].
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.
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
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Table 1. Description of variables.
Variable possible range Valid N Min Max Mean Standard
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
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
- -
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
Tumour stage 1.52 (0.20)
p < 0.002
Tumour grade 1.07 (0.15)
p < 0.647
Age at surgery 1.04 (0.22)
p < 0.029
Sex 1.50 (0.56)
p < 0.274
* 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
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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
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.
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