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Social Support
Breast cancer patients with close social and emotional ties in the first six months after diagnosis have better survival and fewer recurrences within the first few years, although the extra benefits appear to stop at about three years. Those are the results of a study of approximately 2,000 women in China, published in the Journal of Clinical Oncology (2011;29:406-412).
Researchers at Vanderbilt-Ingram Cancer Center and colleagues at the Shanghai Institute of Preventive Medicine found that women with the highest satisfaction with marriage, family, and friends at six months had a 38% reduced risk of mortality and a 48% lower risk of recurrence, when compared with those with poor social ties, while women reporting “favorable” interpersonal relationships had a 35% lower risk.
Meira Epplien, PhD, Assistant Professor of Medicine at VICC, and colleagues studied patients enrolled in the Shanghai Breast Cancer Survivor Study for a median of 4.8 years after diagnosis. Participants were interviewed six and 36 months post-diagnosis. Questions included physical issues like sleep, eating, pain, psychological well-being, social support and material well-being, and quality-of-life (QOL) scores were assigned based on their responses.
“In this prospective study we collected extensive information on treatment and other well-established clinical predictors, such as stage, estrogen and progesterone status, and initial treatment type, which allows us to adjust for these potential confounders,” Dr. Epplien said in an interview. “The biggest surprise was that physical well-being was less important than strong social ties in breast cancer outcomes.”
During a median follow-up of 4.8 years after the initial QOL assessment, the team documented deaths and cancer recurrence and compared the data with the initial six- and 36-month scores. Only social well-being at six months was significantly associated with fewer deaths or recurrences.
“Because social well-being appears to be such an important prognostic factor for breast cancer recurrence or death, we feel there are many opportunities for designing interventions to maintain or enhance social support soon after diagnosis,” Dr. Epplien noted.
It is less clear why the positive influence of a strong social support network was no longer statistically significant when measured after three years, she said, but the research is ongoing.
“I think this study suggests that investing in family relationships and civic support in the first year after diagnosis is beneficial for patients, and we really need to take a more proactive stance on social factors.”
Many studies have shown the value of support groups for cancer survivors, but there is a lot of variability in terms of availability of such groups depending on where a patient lives, even in the United States, Dr. Epplien noted.
The emergence of social networking and Internet support groups, together with better counseling of family members, could potentially benefit cancer survivors, and future studies of these interventions are warranted, she said.
Mind Matters
Asked for his opinion for this article, David Spiegel, MD, Professor of Psychiatry and Behavioral Sciences at Stanford University School of Medicine and Director of the Center on Stress and Health there, said that oncologists need to let patients know about the evidence that social support and emotional support can actually improve their chances of recovery.
“This paper adds to the mounting evidence that social isolation increases risk for cancer progression and earlier mortality; it is a step in the right direction,” he said. “Unfortunately, just at the time when cancer patients need more social support, they often get less. A diagnosis of cancer is like the proverbial ‘elephant in the room.’ Not only do patients tend to withdraw, but friends and acquaintances are uncomfortable with the “C” word at a time when their support is most needed.”
He and his colleagues published a study in the same issue of JCO (2011;29:413-420) – first author was Janine Giese-Davis, PhD — showing that decreasing depression among women with metastatic breast cancer in the baseline year predicted significantly longer survival (median of 4.5 years) compared with those with increasing depression (median of two years).
Also this year, in a Commentary in the Journal of the American Medical Association, (2011; 305:502-503), Dr. Spiegel emphasized that social support plays a significant role in helping patients with end-stage cancers, both emotionally and medically.
For example, in a randomized trial published last year in the New England Journal of Medicine, patients with small-cell lung cancer who received an average of four palliative care visits lived longer than those who received standard anticancer care (median survival of 11.65 vs 8.9 months).
“This apparently counterintuitive finding suggests that emotional support is not only psychologically beneficial but also medically efficacious,” he wrote.
“I know of at least seven papers now that support the hypothesis that cancer patients benefit in terms of survival from more, not less, social interaction and emotional support,” he said.
“We still treat the body and not the person. The way the patient copes with their illness is a therapeutic resource, especially in situations where other medical interventions have limited effectiveness. We're finding out just how important emotions and social support are to recovery and survival. We've made some headway, but we have a long way to go. It isn't mind over matter, but mind matters.”
A 2007 systematic review of the potential influence of psychosocial factors in breast cancer outcomes by researchers at the Alfa Institute of Biomedical Sciences in Athens, Greece, and Tufts University School of Medicine, concluded that while most studies showed a significant relationship between psychosocial factors and survival, actual psychosocial variables were not consistently measured across studies, and many of the psychosocial variables with survival/recurrence were not consistent across studies (Breast Cancer Res 2007;9:R44).
Of 31 studies examined, 81% showed a statistically significant link between at least one psychosocial variable and outcome, and the ones associated with better prognosis included stronger social support and marriage, while depression and constraining emotions were associated with decreased survival.
All the findings add further to the evidence relating to the significant role of psychosocial factors on the outcome of breast cancer patients, said the senior author of the Breast Cancer Research study, Petros I. Rafailidis, MD, a researcher at the Alfa Institute.
“The findings [of the two JCO studies] are in concordance with a significant number of studies supporting the same, although one has to acknowledge that there are other studies that have shown no impact regarding social support and breast cancer survival,” he wrote via email. “Nevertheless, one cannot ignore the findings of the [Epplein and Giese-Davis] studies, as they point to the significance of factors other than medical/surgical/radiotherapy treatment. The fact that the studies were performed in diverse clinical settings (China and North America) implies that psychosocial factors may indeed play a significant role.”
Nonetheless, the inherent limitation in many of these studies is that different evaluation tools were used to compare their findings, Dr. Rafailidis added. “Multicenter studies using common evaluation methods for large populations are necessary to evaluate further the effect of such psychosocial factors.”
