Psycho-Oncology Psycho-Oncology 19: 160169 (2010) Published online 2 February 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.

1536

Personality traits and psychosocial stress: quality of life over 2 years following breast cancer diagnosis and psychological impact factors
Kristin Ha rtl1, Jutta Engel2, Peter Herschbach3, Hans Reinecker4, Harald Sommer1 and Klaus Friese1
1 2

Department of Gynecology and Obstetrics, Ludwig-Maximilians-University, Munich, Germany Munich Cancer Registry of the Munich Cancer Centre at the Institut of Medical Informatics, Biometry and Epidemiology, Ludwig-MaximiliansUniversity, Munich, Germany 3 Department and Outpatient Clinic of Psychosomatic Medicine and Psychotherapy, Division of Psychosocial Oncology, Technical University of Munich, Germany 4 Faculty of Psychology, Section for Clinical Psychology and Psychotherapy, Otto-Friedrich-University, Bamberg, Germany * Correspondence to: Department of Gynecology and Obstetrics, Klinikum der, Ludwig-MaximiliansUniversitaet Muenchen, Maistr. 11, 80337 Munich, Germany. E-mail: kristin.haertl@med.unimuenchen.de

Abstract
Objective: The aim of this study was to investigate changes in the quality of life (QoL) and body image among breast cancer patients over 2 years and to examine dierent predictive factors for QoL 2 years after the primary operation. Methods: A total of 203 women with a primary diagnosis of breast cancer completed the questionnaires 2 weeks and 6, 12, 18, and 24 months after surgery. Quality of Life Questionnaire (QLQ-C30), Breast Cancer Specic Quality of Life Questionnaire Module (QLQ-BR23), Questionnaire on Stress in Cancer Patients (QSC-R23), Freiburg Personality Inventory (FPI-R), Life Orientation Test (LOT) were used as standardized measures. Results: The overall QoL and most functional and symptom scales improved during the 2-year period. However, cognitive functioning, body image, and the three symptom scales of insomnia, constipation, and diarrhea did not change. Age was only capable of predicting physical functioning, whereas tumor size, axillary surgery, and adjuvant chemotherapy were not predictive of the long-term QoL functional scores. Initial distress was the most potent predictive factor for long-term QoL. Baseline functioning predicted functional QoL scores 2 years later. And higher scores for neuroticism were associated with a poorer QoL. However, optimism was not capable of predicting the QoL 2 years later. Conclusion: Screening measures should be implemented at the time when breast cancer is diagnosed, in order to identify psychologically vulnerable patients and oer them professional psycho-oncological help. Copyright r 2009 John Wiley & Sons, Ltd.
Keywords: cancer; oncology; quality of life; distress; neuroticism

Received: 28 July 2008 Revised: 13 December 2008 Accepted: 15 December 2008

Introduction
With the increasing numbers of long-term survivors of breast cancer, there has been growing interest in oncological research in examining psychological adaptation and quality of life (QoL) over time and factors that may aect this. Most studies have focused on clinical factors aecting QoL in breast cancer patients, such as the type of surgery, adjuvant treatment, clinical tumor size, number of positive axillary nodes, and comorbidity [15]. Age has been examined as a possible sociodemographic impact factor aecting QoL [69]. Other sociodemographic factors, such as marital status, living situation, education level, and occupation have been investigated to a lesser extent [2,4]. Several studies have demonstrated that

psychological factors, rather than illness-related factors or sociodemographic variables, are predictive of emotional well-being and QoL among breast cancer patients [1012]. Pessimism and optimism [1214], self-image and perceived control [15], as well as chronically elevated distress [16], have been investigated as psychological impact factors. Other personality factors capable of inuencing QoL, such as neuroticism or extroversion, have received little attention. The present study has two aims: rstly, to investigate changes in QoL and body image among women with primary breast cancer over a 2-year period following diagnosis; and secondly, to examine dierent predictive factors for QoL 2 years after the primary operation in a multivariate model. Following a biopsychosocial approach, it

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was assumed that oncological, sociodemographic, and psychological factors inuence the way in which patients adapt to a life-threatening illness. On the basis of breast cancer research, age was selected as a possible sociodemographic impact factor, and tumor stage, axillary surgery, and adjuvant chemotherapy were regarded as possible oncological predictors. Whether womens personality inuences the way in which they adapt to cancer over the longer term is an open question. This study investigated two personality traits: optimism and neuroticism. Additional topics of interest were whether a high degree of distress following the diagnosis of cancer and surgery is predictive of the long-term QoL and whether early psychological adaptation to cancer is associated with long-term adaptation. The following specic hypotheses were examined: (1) The overall QoL, physical, social, emotional, cognitive, role functioning, body image, and healthrelated symptoms improve over time. (2) Age as a sociodemographic factor, tumor size, axillary surgery, and adjuvant chemotherapy as oncological factors are able to predict the QoL 2 years later. (3) Psychological predictive factors: initial distress following the diagnosis of breast cancer and surgery, and optimism and neuroticism as personality traits, are able to predict QoL 2 years later. (4) Early adaptation to the diagnosis of breast cancer and surgery is associated with long-term adaptation: baseline functioning in women with breast cancer is able to predict the QoL 2 years later. The overall aim of the study was to detect factors capable of identifying women who tend to be more vulnerable to maladaptation and a poorer longterm QoL than others.

questionnaires. Patients receiving neoadjuvant cytotoxic therapy and women with a diagnosis of psychosis or severe personality disorder were excluded. Finally, patients with recurrent breast cancer and those who died during the follow-up period were excluded from the analysis. At baseline, 278 women with breast cancer received the questionnaires at the Department of Gynecology and Obstetrics, Ludwig-MaximiliansUniversity of Munich, and at the Department of Gynecology/Breast Center in Dachau. During the 2-year follow-up period, seven patients died and 16 patients developed recurrent breast cancer; 255 women were therefore included in the study sample. Fifty-two patients did not complete the questionnaires at either 6, 12, 18, or 24 months, representing an overall drop-out rate of 20.4%. A nal total of 203 subjects completed the questionnaires at all ve measurement times (t1t5).

Measures
QoL was evaluated using the Quality of Life Questionnaire (QLQ-C30), version 3.0, published by the EORTC Study Group on Quality of Life [17,18]. The QLQ-C30 questionnaire includes a global health status/QoL scale; ve functional scales that evaluate physical, role, emotional, cognitive, and social functioning; and eight symptom scales that measure fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss, constipation, and diarrhea. Higher mean scores on the QoL scale and the functional scales represent better QoL and functioning; higher mean values on the symptom scales represent more symptoms. The Breast Cancer Specic Quality of Life Questionnaire Module (QLQ-BR23) [19] includes scales specic for breast cancer. This study used the subscales of body image, arm symptoms, and breast symptoms, as studies have reported longlasting problems in these areas [4,20,21]. Higher mean scores on the body image scale represent better functioning, whereas higher mean scores on the symptom scales represent more symptoms. The Questionnaire on Stress in Cancer Patients, revised version (QSC-R23) [22,23] was developed to assess psychosocial stress in cancer patients. This tool presents respondents with a wide range of cancer-specic stress situations, which have to be rated in terms of relevance and amount of distress. The 23 items are aggregated to make up ve subscales (fears, psychosomatic complaints, everyday life restrictions, information decits, and social strains) and a total score for psychosocial distress. Higher mean scores on the subscales and the total score represent greater psychosocial distress. The Freiburg Personality InventoryRevised (FPI-R) [24,25] is a questionnaire on personality
Psycho-Oncology 19: 160169 (2010) DOI: 10.1002/pon

Methods Study design and participants

At the time of their primary surgical treatment, patients with breast cancer were asked to complete the QoL questionnaire ve times over a 2-year period. Participants were approached by medical doctors who provided them with information about the aim of the study and the study design and asked them to provide written informed consent. The rst assessment took place within 2 weeks after primary surgical treatment and before adjuvant therapy. Over a 2-year period, QoL questionnaires were sent at intervals of 6 months to the women who agreed to participate in the study. Questionnaires regarding personality traits were completed only once, at the baseline. The study design was approved by the local ethics committee. The following patients were included: women with a primary diagnosis of breast cancer, TNM stage pT14, pN03, pM0, or carcinoma in situ, and an ability to read German and understand the
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traits that was developed for the adult population in Germany. The present study used the subscale for neuroticism from it, which contains 14 statements with which the patients have to agree or disagree. Higher scores on this subscale indicate greater neuroticism/emotionality, characterizing the person as being emotionally unstable, hypersensitive, anxious, and as having many psychosocial and psychosomatic problems. Lower scores on the subscale characterize the person as being emotionally stable, composed, self-condent, and satised with life [24]. The German version of the Life Orientation Test (LOT) [26,27] was used to assess the personality trait of dispositional optimism. The authors dened optimism in terms of generalized expectations of the occurrence of good outcomes in life and construed it as a stable personality characteristic [27]. The LOT consists of eight itemsfour positively worded and four negatively worded statements about outcome expectations in general, with which the respondent has to agree or disagree. Higher scores indicate greater optimism and lower scores indicate lesser optimism (referred to as pessimism).

Drop-out analysis
MannWhitney U tests were used to test for dierences between drop-outs (n 5 52) and the remaining patients (n 5 203) at baseline. The baseline scores for QoL, role functioning, emotional functioning, cognitive functioning, and body image did not dier (P40.05). The baseline values for all symptom scores in the QLQ-C30 and for the arm and breast symptom scores in the QLQ-BR23 did not dier (P40.05). Both groups also had similar scores for psychosocial stress, optimism, and neuroticism at baseline (P40.05). The two groups were also similar with regard to oncological and sociodemographic factors such as tumor size, number of positive axillary nodes, type of surgery, adjuvant treatment, age, and marital status. There were two dierences: women who did not complete the questionnaires at all ve measurement timepoints had poorer physical functioning (69.1 vs 76.5, P 5 0.034) and poorer social functioning (58.0 vs 70.9, P 5 0.005) at baseline in comparison with the study sample.

Results Patients demographic and clinical characteristics

Statistical analyses
Linear transformation was used to standardize the raw scores for the QoL parameters, so that all scores ranged from 0 to 100. In accordance with the scoring manual, the questionnaire items from the QLQ-C30 and the QLQ-BR23 were encapsulated in scales for the categories global health status QoL, functional scales, and symptom scales. The total score for psychosocial distress was computed as the mean of the 23 item scores from the QSC-R23. Optimism was calculated by summing the eight item scores from the LOT and neuroticism by summing the 14 item scores from the FPI-R. The following statistical tests were performed. To test for changes in QoL and body image over the ve measurement time-points, the non-parametric Friedman test for three or more dependent groups was used. Stepwise multiple regression analysis was conducted to predict QoL, functional scales and body image 2 years after primary surgical treatment. Multiple regression analysis included sociodemographic, oncological, and psychological variables: age, tumor size, axillary surgery, adjuvant chemotherapy, early psychosocial distress, optimism, neuroticism, and baseline QoL. A stepwise multiple regression analysis was performed separately for each functioning domain after 2 years of follow-up. The signicance level was set at a two-tailed P-value of o0.05 for all calculations. The Statistical Package for the Social Sciences (SPSS) program, version 15.0, was used for analysis.
Copyright r 2009 John Wiley & Sons, Ltd.

The mean age of the 203 participating patients at time of primary diagnosis was 58.4 years (range: 3384, SD: 10.5). With regard to staging, 60.5% of the patients were diagnosed with stage pT1ac (tumor size p2 cm), 31.0% with stage pT2pT4 (tumor size 42 cm), and 8.5% had ductal carcinoma in situ (DCIS). Lymph node metastases were absent in 71.9% (pN0) and present in 28.1% (pN1, pN2, pN3) of the patients. The primary surgical treatment consisted of either breast-conserving therapy (BCT, n 5 187) or modied radical mastectomy (n 5 16). A total of 111 patients underwent axillary dissection, and 60 patients had sentinel lymph node biopsies. Radiotherapy was administered to 171 patients, cytotoxic therapy to 60 patients, and endocrine therapy to 168 patients. Descriptive data for the patients are summarized in Table 1.

Change of QoL scales over 2 years of follow-up

Table 2 shows the mean values and standard deviations for the QLQ-C30 and QLQ-BR23 scores over the ve measurement time-points, as well as the P-values for the Friedman test. Global health status/QoL and four of the ve functional scalesnamely, physical, role, emotional, and social functioningsignicantly increased during the 2-year follow-up period (Po0.001). The cognitive functioning subscale did not change signicantly over the assessment time-points (P 5 0.476), nor did the body image
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Table 1. Demographic and clinical characteristics of breast cancer patients (n 5 203)

N Demographics at the time of the primary diagnosis Age o65 years X65 years Married Children More than 9 years education Employed Medical data at the time of the primary diagnosis Primary cancer diagnosis and tumor size Breast cancer, pT1ac (p2 cm) Breast cancer, pT2pT4 (42 cm) DCIS Lymph node metastases Absent (pN0) Present (pN1, pN2, and pN3) Menopausal status Premenopausal Postmenopausal Primary surgical treatment Type of surgery BCT Mastectomy Axillary surgerya Axillary dissection Sentinel lymph node biopsy No axillary surgery Adjuvant Treatment Radiotherapy Cytotoxic therapy Endocrine therapy %

143 60 128 150 107 100

70.4 29.6 63.1 73.9 54.0 49.2

121 62 17 143 56 44 158

60.5 31.0 8.5 71.9 28.1 21.8 78.2

187 16 111 60 18 198 171 60 168

92.1 7.9 58.7 31.7 9.5 97.5 84.2 29.6 82.8

scale from the QLQ-BR23 (P 5 0.074). The results are shown in Figure 1. Scores for cognitive functioning remained stable over time, whereas the other functional scales from the QLQ-C30 showed an increase over the assessment times. The largest increase in these scales was during the rst 6 months; the mean dierences varied from 5.7 (physical functioning) to 15.0 (role functioning). The mean scores for arm symptoms, breast symptoms, fatigue, nausea and vomiting, pain, dyspnea, and appetite loss decreased signicantly over time (Po0.05). Again, the greatest degree of change in these health-related symptoms was observed during the rst 6 months after the diagnosis of breast cancer and surgery. There were two exceptions: on the breast symptom scale, slightly more improvement was observed during the second 6-month period (mean dierence: 6.3) in comparison with a decrease during the rst 6 months (mean dierence: 5.4). In addition, dyspnea did not change during the rst year of follow-up, but during the second year. Three symptom scales, however, did not change during the follow-up: symptoms of insomnia, constipation, and diarrhea remained stable over time (P40.05).

Predictors for QoL scales 2 years after the primary operation

For each dependent variable, Table 3 presents the predictor variables that were included in the regression model, model-adjusted R2, beta, and P-values for the overall regression and the coecients.

BCT, breast-conserving therapy; DCIS, ductal carcinoma in situ. a Data of axillary surgery not available in 14 cases.

Table 2. Mean quality of life scores over the five measurement time-points (n 5 203)
Mean t1 (SD) Mean t2 (SD) Mean t3 (SD) Mean t4 (SD) Mean t5 (SD) Chi-squared P (Friedman test) Functional scales Global health status/QoL Physical functioning Role functioning Emotional functioning Cognitive functioning Social functioning Body image Symptom scales Arm symptoms Breast symptoms Fatigue Nausea and vomiting Pain Dyspnea Insomnia Appetite loss Constipation Diarrhea 57.9 76.5 59.2 58.3 78.6 70.9 80.0 30.0 32.8 42.5 9.1 32.3 23.0 40.9 16.3 14.0 6.9 (21.2) (20.5) (31.0) (26.2) (26.0) (29.1) (25.7) (24.4) (23.3) (26.9) (20.0) (28.4) (27.3) (33.5) (26.6) (26.7) (17.4) 64.7 82.2 74.2 65.9 79.6 78.3 80.3 24.1 27.4 36.2 5.0 26.4 24.3 43.3 9.0 13.3 8.4 (21.0) (18.2) (27.5) (24.7) (27.5) (26.6) (27.1) (25.1) (22.4) (27.8) (14.0) (28.3) (29.1) (35.2) (20.5) (26.6) (20.7) 67.0 82.4 76.8 66.2 78.3 80.2 81.0 21.7 21.1 33.9 3.9 21.8 23.2 42.0 5.6 9.4 7.6 (22.7) (20.3) (28.4) (27.4) (27.8) (27.5) (27.3) (23.8) (19.7) (26.4) (12.0) (26.5) (29.8) (35.0) (15.6) (22.1) (18.7) 68.9 84.1 79.7 67.3 78.7 82.3 81.0 20.7 18.0 31.7 3.5 23.2 20.9 39.7 5.3 9.5 7.1 (20.6) (19.5) (27.6) (26.6) (27.7) (25.2) (26.8) (24.9) (19.2) (26.9) (11.4) (27.6) (28.7) (34.9) (15.7) (22.4) (17.8) 70.6 85.0 83.0 69.6 78.3 84.1 82.6 21.0 17.3 30.3 4.8 18.5 19.4 37.6 4.8 10.8 9.0 (19.7) (16.9) (24.8) (27.8) (26.6) (24.0) (25.6) (24.9) (18.0) (26.0) (11.9) (24.9) (26.9) (31.4) (13.4) (23.8) (20.5) 69.1 69.0 132.5 47.8 3.5 59.4 8.5 37.5 124.6 60.8 26.5 64.9 9.6 6.6 63.3 5.3 2.0 o0.001 o0.001 o0.001 o0.001 0.476 o0.001 0.074 o0.001 o0.001 o0.001 o0.001 o0.001 0.047 0.156 o0.001 0.254 0.733

t1: after primary surgical treatment; t2: 6 months after surgery; t3: 12 months after surgery; t4: 18 months after surgery; t5: 24 months after surgery. Friedman test: chi-squared, df 5 4; a two-tailed P-valueo0.05 is considered to indicate statistical significance.

Copyright r 2009 John Wiley & Sons, Ltd.

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Initial distress was the strongest predictor for long-term QoL. In all of the regression models with the exception of cognitive functioning, initial distress was predictive of a poorer QoL, poorer functional scores, and a poorer body image after 2 years. Initial physical functioning, role functioning, cognitive functioning, and body image were predictive variables for functional scores 2 years later. The initial level of distress was the only predictive variable in the regression model for the social functioning scale, and baseline functioning and initial distress accounted for 37% of the variance in the body image scale at the 2-year follow-up. Neuroticism was included in the regression models of several functioning scales. Higher scores for neuroticism at baseline predicted a poorer global health status (P 5 0.001), poorer role functioning (P 5 0.043), poorer emotional functioning (P 5 0.015), and poorer cognitive functioning (P 5 0.013). Older age was predictive of poorer
90

physical functioning 2 years after primary surgery (P 5 0.002). None of the oncological variables tumor size, axillary surgery, or adjuvant chemotherapy was included in the regression models; they did not signicantly predict QoL functional scores at follow-up. The same applied to the personality trait of optimism. Optimism scores at baseline did not signicantly predict the QoL functional scores at 2 years.

Discussion
The aims of the study were rstly, to investigate changes in QoL and body image in breast cancer patients over a 2-year period and secondly, to examine dierent predictive factors for QoL 2 years after primary operation. Several limitations of the study design should be considered.

80

70

60

50 t1
QoL Physical f.

t2
Role f.

t3
Emotional f.

t4
Cognitive f.

t5
Social f.

Figure 1. Mean QoL functional scores over the five measurement time-points (n 5 203)

Table 3. Predictors for quality of life scales 2 years after the primary operation (n 5 203)
Dependent variables/QoL scales Global health status/QoL Physical functioning Predictor variables Initial distress Neuroticism Initial distress Initial physical fuctioning Age Initial distress Initial role fuctioning Neuroticism Initial distress Neuroticism Initial cognitive fuctioning Neuroticism Initial distress Initial body image Initial distress Model-adjusted R2 0.21 0.40 Pa (F-Test) o0.001 o0.001 Beta 0.30 0.25 0.43 0.30 0.18 0.36 0.16 0.15 0.40 0.18 0.50 0.16 0.48 0.53 0.14 Pb (t-test) o0.001 0.001 o0.001 o0.001 0.002 o0.001 0.030 0.043 o0.001 0.015 o0.001 0.013 o0.001 o0.001 0.045

Role functioning

0.27

o0.001

Emotional functioning Cognitive functioning Social functioning Body image

0.25 0.34 0.22 0.37

o0.001 o0.001 o0.001 o0.001

A two-tailed P-valueo0.05 is considered to indicate statistical significance. a P-value from the F-test for significant overall regression. b P-value from t-test for significant coefficients.

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Limitations of the study

The selection of patients is positively biased, as women receiving neoadjuvant therapy and those with metastases or recurrent breast cancer were not taken into consideration. As a consequence, the sample presented quite good clinical data at the baseline, with the majority of patients being diagnosed with pT1ac and pN0 and 92% being treated with BCT. Patients undergoing neoadjuvant therapy who received cytotoxic medicaments after the histological diagnosis of breast cancer, but before primary surgery were excluded. This subgroup was excluded because in the study design, the rst measurement point was set within 2 weeks after primary surgical treatment. For patients receiving adjuvant therapy, primary surgery follows shortly after diagnosis, and in patients with neoadjuvant therapy, the time lag may dier widely. We excluded patients with metastases at baseline and those with recurrent breast cancer during the follow-up, as women with or without metastases or recurrent cancer dier widely with regard to their QoL. The data suggested that recurrent breast cancer in particular is associated with severe impairments in QoL [28,29]. It is therefore dicult to compare women with and without recurrence within the same sample. In summary, this selection bias needs to be taken into account when the study results are generalized to other breast cancer patients. Another selection bias results from the decision to include only patients who completed the questionnaires at all ve measurement time-points, thereby excluding deceased patients and patients who declined to participate further in the study. While the number of deceased patients in the sample was quite small (n 5 7), the overall drop-out rate of 20% during the 2-year follow-up period is comparable to other follow-up studies. With regard to the drop-out analysis, drop-outs and study patients were similar in terms of oncological, sociodemographic, and psychological factors and most QoL scores. Two dierences were detected, however: at the baseline, the drop-outs had poorer physical functioning and poorer social functioning in comparison with the study patients; both of these factors could be interpreted as possible reasons for withdrawing from the study. With regard to the inclusion criteria for the sample, a point of criticism might be that women with breast cancer and DCIS were evaluated in the same data analysis. However, the tests for dierences between these two subgroups with regard to QoL scales at baseline and at the 2-year follow-up were not signicant. There were only two exceptions: women with DCIS had less appetite loss at the baseline and better role functioning at the follow-up in comparison with women with breast cancer.
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The selection of age, tumor size, axillary surgery, and adjuvant chemotherapy as sociodemographic and oncological impact factors on the QoL of breast cancer patients is based on clinical studies [19]. The impact of primary surgical treatment (BCT vs mastectomy), especially in relation to long-term body image, would also have been of interest [3,5], but the very small subgroup of patients treated with mastectomy (8%) did not allow statistical analysis. The psychological predictors investigated are based on recent studies that have demonstrated the importance of increased distress, early adaptation, and personality traits [10,1214,16,30] and on the coping theory proposed by Lazarus and Folkman [31] as a biopsychosocial framework. However, the selection of predictor variables inevitably disregards the fact that there are many other variables that may also inuence QoL and well-beingsuch as radiotherapy or endocrine therapy [32,33] on the oncological side, and self-esteem or self-ecacy [15] on the psychological side. Methodological weakness: The use of regression analysis requires critical discussion. The main reason for the choice of regression analysis lay in the fact that only a few published studies have so far examined psychological predictors of long-term QoL and adaptation. As these studies used regression analysis [10,12,14,30,3436], the principal aim of the present study was to compare data with these other publications and attempt to replicate their ndings and add other possible predictors. One example is a recent study by Schou et al. [14], who used multiple regression analysis to investigate oncological and psychological predictors of QoL scores 1 year after breast cancer surgery. Multiple regression analysis is used to predict the score on a continuous variable (the dependent variable) from scores on several, usually continuous, variables (the independent variables) [37]. In the present study, age is a continuous variable, whereas QoL scores, distress, optimism, and neuroticism are strictly speaking ordinally scaled. According to standard procedures of statistical practice [37], we decided to treat these psychological scales as continuous variables, partly because the QoL scores were standardized from 0 to 100. Tumor size (pT1ac vs pT2pT4), axillary surgery, and adjuvant chemotherapy are dichotomous independent variables. However, following the general procedures of multiple regression analysis used in the behavioral sciences, regression analysis can be used with continuous or dichotomous independent variables or combinations of the two [37,38]. In conclusion, it was decided to conduct regression analysis in order to ensure comparability with the methodology used in other international clinical studies, while bearing in mind the potential weaknesses of the methods when discussing the results. And nally, due to the fairly small sample
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size, no adjustments for multiple testing were made, and the results therefore need to be interpreted with caution.

Discussion of the studys hypotheses

Change of QoL

The results support the studys hypothesis that the QoL of newly diagnosed breast cancer patients changes over time. The overall QoL, most functional and symptom scales improved during the 2-years follow-up period. The greatest changes in health-related QoL, functioning, and symptoms were observed during the rst 6 months. Five scales, however, did not change: cognitive functioning, body image, and symptoms of insomnia, constipation, and diarrhea did not increase or decrease during the follow-up period. At the time of diagnosis and primary surgery, being confronted with breast cancer as a lifethreatening disease has a negative impact on well-being and QoL. Because most patients are likely to have recovered 6 months later from the shock of the diagnosis, surgery, and hospitalization and will have completed radiotherapy and cytotoxic therapy, an improvement in their QoL would be expected. Interestingly, after 12, 18, and 24 months there were only minor changes in QoL. Increasing demands in family and working life and decreasing professional support from doctors might lead to these minor changes. Similarly, improvements in arm, breast, and other cancerrelated symptoms can be explained by recovery from surgery and adjuvant therapy, with physiotherapy and rehabilitation procedures. Problems with insomnia, constipation, and diarrhea did not change; these probably represent side eects of surgery and therapy that improve slowly. Whereas the baseline scores for constipation and diarrhea were not high, representing fairly minor impairments, considerable problems with insomnia during the whole follow-up period could be interpreted as a psychosomatic symptom of ongoing distress. The lack of change in cognitive functioning, a nding that is in line with previous studies [14], has been under discussion as a long-lasting neuropsychological eect of chemotherapy [39,40]. In the study sample, 30% of the patients received cytotoxic therapy; a follow-up period of 2 years might be too short for improvements to be observed. However, it should be borne in mind that cytotoxic therapy was not capable of signicantly predicting cognitive functioning at the 2-year follow-up in the multiple regression analysis. In addition, the baseline assessment in this sample appears to indicate only moderate impairment of cognitive functioning. Finally, the lack of change with regard to body image needs to be considered in comparison with studies that have demonstrated
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an improvement in body image over time, especially in women who have undergone mastectomy [41]probably due to increasing skills in coping with body image impairment. The controversial nding of a lack of change in body image might be explained by the high percentage of women in the present study who were treated with BCT (92%); the scores for body image in the sample were consequently fairly high over all measurement time-points and are thus not comparable with data from studies in which the majority of patients were treated with mastectomy [20]. Published results regarding the long-term QoL in breast cancer patients have been heterogeneous. Some studies have described long-term impairment of QoL, impaired functioning, and continuing symptoms [42,43], as well as a high percentage of distress in breast cancer survivors [16,35], whereas others have reported an improving QoL over time [21,44]. Arndt et al. [43] compared breast cancer patients with reference data from the general population. Three years after diagnosis, breast cancer patients had poorer role functioning and poorer emotional, cognitive, and social functioning, as well as more symptoms of insomnia, fatigue, and dyspnea, especially at younger ages.
Age as a sociodemographic predictor and oncological predictors

Age as a sociodemographic factor for predicting QoL 2 years after surgery was only able to predict physical functioning. Older age was predictive of poorer physical functioning at the 2-year followup. Age as an important predictor of physical functioning among breast cancer survivors was also conrmed by a recent study [15]. With growing age, physical problems are likely to increase, even irrespective of the cancer diagnosis. However, the nding that age was not predictive of other QoL domains contradicts the hypothesis, as well as previous studies that have reported greater distress in younger breast cancer patients in both the short term and long term [79]. This greater impairment of QoL in the younger age group was explained by greater work-related and family-related demands, less adequate strategies for coping with disease, and health-related restrictions. One explanation of our dierent nding might be a statistical cause. As distress and age are not independent, the eect of age on QoL may be confounded by initial distress as a more potent predictor. Other groups have concluded that the results about the relationship between age and breast cancer adaptation are contradictory [15,45]. None of the oncological factors investigated tumor size, axillary surgery, and adjuvant chemotherapywas predictive of the long-term QoL functional scores. These ndings are dicult to explain; for example, it is a surprising result that
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chemotherapy did not appear to aect long-term cognitive functioning and that axillary surgery did not have a long-term inuence on physical functioning. Tumor size is an important prognostic factor, as it inuences the surgery and adjuvant therapy and is therefore expected to aect wellbeing and QoL. It is possible that the importance of the tumor stage is not suciently communicated to patients by doctors, or that patients who are not familiar with oncological subjects view their diagnosis as life-threatening regardless of the tumor stage. Nevertheless, the results presented here are in agreement with previous studies, which concluded that initial medical variables did not have a predictive role in relation to well-being and QoL [1012,15].
Psychological predictors

Initial distress was the strongest predictive variable for long-term QoL. With the exception of cognitive functioning, initial distress predicted a poorer QoL, poorer functional scores, and a poorer body image after 2 years. Similarly, in two previous studies, initial distress was found to be predictive of psychological and physical QoL in breast cancer patients after a 1-year follow-up period [16,30]. The results of the present study support the hypothesis that the experience of distress of a woman confronted with a life-threatening disease will have long-lasting eects on her subjective well-being. According to the coping theory developed by Lazarus and Folkman [31], a person will experience distress when current demands exceed internal and/ or external resources. Thus, the amount of distress experienced at the time of a breast cancer diagnosis might be moderated by more adequate vs less adequate coping strategies as internal resources and by a more supportive vs less supportive partner/ family as external resources. The personality trait of neuroticism was associated with several QoL scales. Higher scores for neuroticism predicted a poorer overall QoL and poorer role, emotional, and cognitive functioning at follow-up. There are only a few studies that have investigated the role of neuroticism in relation to subjective well-being among breast cancer patients. Millar et al. [16] found that neuroticism was a (minor) predictive factor for psychological morbidity 1 year after treatment for breast cancer. Two studies reported signicant associations between neuroticism and long-term symptoms of fatigue after breast cancer surgery [36,46]. Neuroticism has also been found to be associated with a greater risk for depressive symptoms among breast cancer patients after primary surgical treatment [34]. This result indicates that neuroticism and depression are not unrelated. However, the latter must be understood as reactive, whereas the concept of neuroticism is seen as a stable personality trait. The results of the
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present study conrm the hypothesis that women who are characterized as emotionally unstable, hypersensitive, anxious, and with ongoing problems and physical complaints [24] tend to experience long-lasting diculties in coping with breast cancer. The investigated personality trait of optimism could not signicantly predict QoL functional scores at 2 years. In other studies, however, optimism was found to be predictive of better emotional and social functioning [14], and pessimism predicted anxiety and depression [13] 1 year after breast cancer surgery. In addition, optimism has also been found to be predictive of psychosocial adjustment 513 years after surgery for breast cancer [12]. It is not yet clear why the results of the present study do not replicate the ndings of these other reports. As optimism is associated with baseline distress, QoL, and symptoms [14], the eect of optimism in this study might be confounded by initial distress and initial adaptation as more potent predictors. In conclusion, associations between personality traits and adjustment to breast cancer are not yet clear, and the research results are heterogeneous. The hypothesis that early adaptation to a lifethreatening disease is associated with long-term adaptation was conrmed. Baseline functioning predicted physical, role, cognitive functioning, and body image 2 years later. This nding is in agreement with other reports that baseline functioning among breast cancer patients was the strongest predictive variable for functioning after 1 year [14] and that initial reports of wellbeing predicted well-being among cancer survivors [10,12]. The authors interpreted the latter result as showing substantial continuity between wellbeing shortly after treatment and during longterm survivorship [12]. This continuity might emphasize the great importance of early experiences when one is confronted with a lifethreatening diagnosis, surgery, and treatment procedures.

Conclusions
One aim of this study was to investigate the longterm psychological impact of breast cancer diagnosis and treatment. In summary, most QoL domains signicantly improved over 2 years, with the greatest increase being seen during the rst 6 months. However, the data suggest ongoing moderate impairments of cognitive functioning and body image and continuing symptoms of insomnia and, to a minor extent, of constipation and diarrhea. The second aim was to identify predictors of long-term QoL. In summary, initial distress was the most potent predictor for long-term QoL, followed by baseline QoL and
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neuroticism as further important predictors. Age was only able to predict physical functioning, whereas 2 years after the diagnosis of breast cancer, patients QoL was unrelated to the tumor prognosis, surgical modality, and adjuvant treatment. These results emphasize that the impact of objective cancer-related factors on well-being is slighta nding that has been referred to as the well-being paradox [47], with objectively negative factors in life having relatively little eect on subjective QoL. As medical variables and longterm QoL do not appear to be directly related, psychological variables such as personality traits and coping resources may play an important mediating role. In conclusion, screening for the personality trait neuroticism/emotionality and screening for distress reactions following the diagnosis of breast cancer and surgery can be recommended. Screening measures should be implemented at the time of diagnosis in order to identify psychologically vulnerable patients and oer them professional psycho-oncological support.

9.

10. 11.

12.

13.

14.

15.

Acknowledgements
We are grateful to all of the patients who completed questionnaires. We would also like to thank Dr. R. Schennach, Ms. B. Adolf, Ms. V. Schneider, and Ms. J. Meyndt for collecting the data and Dr. U. Peschers and Dr. J. deWaal of the Department of Gynecology in Dachau/Dachau Breast Center for their cooperation. 16.

17.

References
1. Hu rny C, Bernhard J, Coates AS et al. Impact of adjuvant therapy on quality of life in women with nodepositive operable breast cancer. Lancet 1996;347: 12791284. 2. Bernhard J, Hu rny C, Coates AS et al. Factors aecting baseline quality of life in two international adjuvant breast cancer trials. Br J Cancer 1998;78:686693. 3. Curran D, van-Dongen JP, Aaronson NK et al. Quality of life of early-stage breast cancer patients treated with radical mastectomy or breast-conserving procedures: results of EORTC Trial 10801. Eur J Cancer 1998;34: 307314. 4. Engel J, Kerr J, Schlesinger-Raab A et al. Predictors of quality of life of breast cancer patients. Acta Oncol 2003;42:710718. 5. Ha rtl K, Janni W, Ka stner R et al. Impact of medical and demographic factors on long-term quality of life and body image of breast cancer patients. Ann Oncol 2003;14:10641071. 6. Arndt V, Merx H, Stu rmer T et al. Age-specic detriments to quality of life among breast cancer patients over one year after diagnosis. Eur J Cancer 2004;40: 673680. 7. Kroenke CH, Rosner B, Chen WY et al. Functional impact of breast cancer by age at diagnosis. J Clin Oncol 2004;22:18491856. 8. Kornblith AB, Powell M, Regan MM et al. Long-term psychosocial adjustment of older vs. younger survivors
Copyright r 2009 John Wiley & Sons, Ltd.

18.

19.

20.

21.

22.

23.

24.

of breast and endometrial cancer. Psycho-Oncology 2007;16:895903. Wenzel LB, Fairclough DL, Brady MJ et al. Agerelated dierences in the quality of life of breast carcinoma patients after treatment. Cancer 1999;86: 17681774. Ell K, Nishimoto R, Morvay T et al. A longitudinal analysis of psychological adaptation among survivors of cancer. Cancer 1989;63:406413. Bardwell WA, Natarajan L, Dimsdale JE et al. Objective cancer-related variables are not associated with depressive symptoms in women treated for early-stage breast cancer. J Clin Oncol 2006;24: 24202427. Carver CS, Smith RG, Antoni MH et al. Optimistic personality and psychosocial well-being during treatment predict psychosocial well-being among long-term survivors of breast cancer. Health Psychol 2005;24:508516. Schou I, Ekeberg O, Ruland CM et al. Pessimism as a predictor of emotional morbidity one year following breast cancer surgery. Psycho-Oncology 2004;13: 309320. Schou I, Ekeberg O, Sandvik L et al. Multiple predictors of health-related quality of life in early stage breast cancer. Data from a year follow-up study compared with the general population. Qual Life Res 2005;14:18131823. Helgeson VS, Snyder P, Seltman H. Psychological and physical adjustment to breast cancer over 4 years: identifying distinct trajectories of change. Health Psychol 2004;23:315. Millar K, Purushotham AD, McLatchie E et al. A 1-year prospective study of individual variation in distress, and illness perceptions, after treatment for breast cancer. J Psychosom Res 2005;58:335342. Aaronson NK, Ahmedzai S, Bergman B et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85:365376. McLachlan S-A, Devins GM, Goodwin PJ. Validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) as a measure of psychosocial function in breast cancer patients. Eur J Cancer 1998;34:510517. Sprangers MAG, Groenvold M, Arraras JI et al. The European Organization for Research and Treatment of Cancer Breast Cancer-Specic quality-of-life questionnaire module: rst results from a three-country eld study. J Clin Oncol 1996;14:27562768. Omne-Ponten M, Holmberg L, Sjo den P-O. Psychosocial adjustment among women with breast cancer stages I and II: six-year follow-up of consecutive patients. J Clin Oncol 1994;12:17781782. Dorval M, Maunsell E, Deschenes L et al. Long-term quality of life after breast cancer: comparison of 8-year survivors with population controls. J Clin Oncol 1998;16:486494. Herschbach P, Marten-Mittag B, Henrich G. Revision und psychometrische Pru fung des Fragebogens zur Belastung von Krebskranken (FBK-R23). Z Med Psychol 2003;12:6976. Herschbach P, Keller M, Knight L et al. Psychological problems of cancer patients: a cancer distress screening with a cancer-specic questionnaire. Br J Cancer 2004;91:504511. Fahrenberg J, Hampel R, Selg H. FPI-R - Das Freiburger Personlichkeitsinventar (7., uberarbeitete und neu normierte Auage): Manual. Hogrefe: Go ttingen, 2001.
Psycho-Oncology 19: 160169 (2010) DOI: 10.1002/pon

Personality traits and psychosocial stress

169

25. Ostendorf F, Fahrenberg J. Testrezension zum Freiburger Perso nlichkeitsinventarRev. Fass. (FPI-R). Z Dierentielle Diagnostische Psychol 1997;18:8186. 26. Scholler G, Fliege H, Klapp BF. Fragebogen zu Selbstwirksamkeit, Optimismus und Pessimismus: Restrukturierung, Itemselektion und Validierung eines Instruments an Untersuchungen klinischer Stichproben. Psychother Psychosom Med Psychol 1999;49:275283. 27. Scheier MF, Carver CS. Optimism, coping and health: assessment and implications of generalized outcome expectancies. Health Psychol 1985;4:219247. 28. Bull AA, Meyerowitz BE, Hart S et al. Quality of life in women with recurrent breast cancer. Breast Cancer Res Treat 1999;54:4757. 29. Northouse LL, Mood D, Kershaw T et al. Quality of life of women with recurrent breast cancer and their family members. J Clin Oncol 2002;20:40504064. 30. Golden-Kreutz DM, Thornton LM, Wells-Di Gregorio S et al. Traumatic stress, perceived global stress, and lifeevents: prospectively predicting quality of life in breast cancer patients. Health Psychol 2005;24:288296. 31. Lazarus RS, FolkmanS. Stress, Appraisal, and Coping. Springer: New York, 1984. 32. Lasry J-CM, Margolese RG, Poisson R et al. Depression and body image following mastectomy and lumpectomy. J Chronic Dis 1987;40:529534. 33. Shimozuma K, Sonoo H, Ichihara K. Analysis of the factors inuencing the quality of life of patients with advanced or recurrent breast cancer. Surg Today 1995;25:874882. 34. Golden-Kreutz DM, Andersen BL. Depressive symptoms after breast cancer surgery: relationships with global, cancer-related, and life-event stress. PsychoOncology 2004;13:211220. 35. Bleiker EMA, Pouwer F, van der Ploeg HM et al. Psychological distress two years after diagnosis of breast cancer: frequency and prediction. Patient Educ Couns 2000;40:209217. 36. Sugawara Y, Akechi T, Okuyama T et al. Occurrence of fatigue and associated factors in disease-free breast

37. 38.

39.

40.

41.

42. 43.

44. 45. 46.

47.

cancer patients without depression. Support Care Cancer 2005;13:628636. Tabachnik BG, Fidell LS. Using Multivariate Statistics (5th edn.). Pearson: Boston, 2007. CohenJ, CohenP, West SG et al. Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences (3rd edn.). Lawrence Erlbaum: Mahwah, NJ, 2003. Ahles TA, Saykin AJ, Furstenberg CT et al. Neuropsychologic impact of standard-dose systemic chemotherapy in long-term survivors of breast cancer and lymphoma. J Clin Oncol 2002;20:485493. Schagen SB, Muller MJ, Boogerd W et al. Late eects of adjuvant chemotherapy on cognitive function: a followup study in breast cancer patients. Ann Oncol 2002;13: 13871397. Harcourt DM, Rumsey NJ, Ambler NR et al. The psychological eect of mastectomy with or without breast reconstruction: a prospective, multicenter study. Plast Reconstr Surg 2003;111:10601068. Dow KH, Ferrell BR, Leigh S et al. An evaluation of the quality of life among long-term survivors of breast cancer. Breast Cancer Res Treat 1996;39:261273. Arndt V, Merx H, Stegmaier C et al. Persistence of restrictions in quality of life from the rst to the third year after diagnosis in women with breast cancer. J Clin Oncol 2005;23:49454953. Bloom JR, Stewart SL, Chang S, Banks PJ. Then and now: quality of life of young breast cancer survivors. Psycho-Oncology 2004;13:147160. Maunsell E, Brisson J, Deschenes L. Psychological distress after initial treatment of breast cancer: assessment of potential risk factors. Cancer 1992;70:120125. Michielsen HJ, Van der Steeg AFW, Roukema JA, De Vries J. Personality and fatigue in patients with benign or malignant breast disease. Support Care Cancer 2007;15:10671073. Herschbach P. Das Zufriedenheitsparadox in der Lebensqualita tsforschung: Wovon ha ngt unser Wohlbenden ab? Psychother Psych Med 2002;52:141150.

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