Table 2 Methods and outcomes of studies examining the association of psychosocial factors and breast cancer survival

Greer et al. 1979 [4]

Clinical and psychological assessment of patients preoperatively and 3 and 12 months postoperatively and then annually for 4 years. Patients were interviewed and completed psychological tests. Rating scales were devised to measure social adjustment (marital, sexual, interpersonal relationships, work record). Depression was measured by Hamilton rating scale, hostility by Caine and Foulds hostility and direction of hostility questionnaire (HDHQ), extraversion and neuroticism by Eysnack personality inventory (EPI), intelligence by Mill Hill vocabulary scale. At follow up examination, ratings of social adjustment and of depression were repeated and patients' psychological responses to cancer were assessed

At 5 years follow up, 33 patients (49%) were alive and well without signs of recurrence, 16 patients (24%) were alive with metastases, 18 (27%) had died of breast cancer; 2 patients died of disorders other than cancer

Psychological responses: denial, fighting spirit, stoic acceptance, and helplessness/hopelessness. Psychosocial factors: social class, reaction on first discovering the breast lump, delay in seeking advice, reaction to stressful events, expression/suppression of anger, depression, hostility, depressive illness (during 5 previous years), psychological stress, sexual adjustment, interpersonal relationships, work record, extroversion, neuroticism, verbal intelligence

Recurrence-free survival was significantly more common among patients who reacted to cancer with denial or fighting spirit than among patients who responded with stoic acceptance, and helplessness/hopelessness

Derogatis et al. 1979 [5]

Initial evaluation of the patient at their second visit to outpatient department. Interview and assessment of psychological symptoms using the SCR-90 R, the Affect Balance Scale (ABS), the Global Adjustment to Illness Scale (GAIS), the Patients' Attitude, Information and Expectancy form (PAIE). The treating oncologist also completed GAIS and PAIE 3 days after the visit. Medical data were also recorded

13 patients lived less than 1 year and were characterized as short-term survivors; 22 patients lived more than 1 year and were characterized as long-term survivors

Joy, contentment, vigour, affection, anxiety, depression, hostility, psychoticism, guilt

Long-term survivors had higher psychological distress and showed higher levels of anxiety (p < 0.1), hostility (p < 0.01), psychoticism (p < 0.01), depression (p < 0.05), guilt (p < 0.05), negative affect total score (p < 0.01), positive symptom total (p < 0.1) and overall general severity index (p < 0.1)

Marshall et al. 1983 [6]

Each patient was asked about the occurrence of traumatic events 5 years before the first recognition of symptoms (deaths, illnesses, divorces, unemployment). Also patients were asked questions about the extension of social involvement (marital status, participation in religious/non-religious groups). Only women whose deaths have been recorded were included in the study

All patients died. Mean of survival of women <46 years in lower and higher stress quartile: 75.8 months and 50.8 months, respectively. Mean of survival of women 45 to 60 years in lower and higher stress quartile: 54 months and 39.2 months, respectively. Mean of survival of women >61 years in lower and higher stress quartile: 53.4 months and 54.9 months, respectively

Stress (deaths, illnesses, divorces, unemployment), social involvement (marital status, relatives and acquaintances, organization memberships)

The single most powerful predictor of survival is stage. The only statistically significant indicator is social involvement only for the younger age group

Jensen et al. 1987 [7]

Assessment of repressive defensiveness with Marlowe-Crown Social Desirability Scale, Bendig Short Form of the Taylor Manifest Anxiety Scale. Assessment of convergent validity with Sackeim and Gur's Self Deception and Other Deception Questionnaires. Assessment of attention to inner experience using Absorption Scale of Tellegen's Differential Personal questionnaire and Huba, Aneshensel, Singer's Short Form of the Imaginal Processes Inventory. The participants in the study also completed the Millon Behavioral Health Inventory. All three groups were equated on variables reflecting known or suspected genetic, hormonal and socioeconomic factors. The groups with cancer were also compared with regard to factors present at diagnosis associated with the progress of the disease at follow-up

At follow-up (G1, 336 days on average for the 11 patients who died and 636 days on average for the rest; G2, 734 days on average) four women in G1 were in remission, four women in G2 developed recurrence. One died from brain tumour unrelated to breast cancer

Repressive defensiveness, helplessness, expression of negative affect, chronic stress, positive constructive daydreaming

All five psychological variables were significant by p < 0.05. Repressive defensiveness, lower levels of expression of negative affect, higher levels of helplessness, chronic stress, positive constructive daydreaming were associated with poorer survival outcome

Jamison et al. 1987 [8]

Filling of eight questionnaires: Situation Response Scale of general trait anxiousness, General Well Being Scale, Health Value Rating Questionnaire, Self Esteem Inventory, Hostility Scale of the Multiple Affect Adjective Checklist, Zung Depression Scale, Spielberg Trait Anxiety Inventory, Multidimensional Health Locus of Control Scale. Demographic data were acquired at testing and medical data from charts

By the time of analysis all the patients had died from their illness. The patients were divided into two groups: short-term survivors (X = 10.8 months) and long-term survivors (X = 30.4 months)

Anxiety, adjustment, self-esteem, hostility, depression, health locus of control

No consistent differences found between short- and long-term survivors on any psychosocial variable assessed

Hislop et al. 1987 [9]

Patients were asked to complete short self-administered questionnaires (90% completed within 3 months of diagnosis). Information was obtained about types of usual activities, extroversion, neuroticism, self-esteem, locus of control, recent life events, coping behavior, psychiatric symptoms (including anxiety, anger, depression, cognitive disturbance such as forgetfulness, difficulty concentrating and making decisions). Clinical data were obtained from medical records

26 deaths (25 attributed to breast cancer) and 38 recurrences over the 4 years of follow-up

Types of usual activities, extroversion, neuroticism, self-esteem, locus of control, recent life events, coping behaviour, psychiatric symptoms (including anxiety, anger, depression, cognitive disturbance such as forgetfulness, difficulty concentrating and making decisions)

Involvement in expressive activities and low level of anger were associated with significantly better survival and disease-free survival. Extroversion was associated with significantly better survival. Low level of cognitive disturbance was associated with significantly longer disease free survival

Cassileth et al. 1988 [10]

Self-report questionnaire including items on seven factors; social ties and marital history, job satisfaction, use of psychotropic drugs, general life evaluation/satisfaction, subjective view of adult health, hopelessness/helplessness, (and one item found to predict survival in patients with cancer) perception of the amount of adjustment required to cope with a new diagnosis

Group II (only this group included breast cancer patients): the total sample of patients in this group was 158, since 3 patients were accrued to the study after the original analysis. Of that total, 7 (4.43%) died without recurrence of their malignancy, 1 (0.63%) was lost to follow-up and 1 (0.63%) developed a new primary breast cancer. Of the remaining 149 patients, 64 (43%) had documented recurrence of their disease, while 85 (57%) remained in remission

Social ties and marital history, job satisfaction, use of psychotropic drugs, general life evaluation/satisfaction, subjective view of adult health, hopelessness/helplessness, perception of the amount of adjustment required to cope with a new diagnosis

Group II: two psychosocial variables were significantly associated with time to recurrence. Those who scored in the middle third of the Hopelessness Scale had significantly lower risk of recurrence (RR = 0.52, 95% CI, 0.28 to 0.96; p = 0.028). Those who scored in the middle third of the total psychosocial score range had greater risk of recurrence (RR = 1.7, 95% CI 1.0 to 2.8; p = 0.04). In further analyses, using low and high groups as covariates and the middle group as reference, extent of disease was the only significant variable

Levy et al. 1988 [11]

Patients were assessed early in the course of hospitalization (before any treatment), reassessed 4 weeks later and at that time their physicians were asked to predict survival time. Patients were given a structured interview and filled out the Affect Balance Scale (ABS)

At the time of analysis 24 of 36 women had died of their disease. Average survival from date of recurrence was 2 years

ABS overall negative mood score, hostility score, overall positive mood score, joy score

Patients who expressed more joy in the baseline testing, who had longer disease-free survival, who were predicted by their physicians to live longer and had fewer metastatic sites had longer survival time (p < 0.001). Positive mood was also associated with living longer (p < 0.002), negative mood (p < 0.004) and hostility (p < 0.004) were associated with shorter survival

Ramirez et al. 1989 [12]

Adverse life events and life difficulties occurring during the postoperative disease free survival were recorded. Adverse life experiences were measured with Bedford College life events and difficulties schedule. Life events were rated as severe if they had threatening implications (that is, death of a husband or child). Difficulties that carried a pronounced threat and persisted at least 6 months were rated as severe (that is, taking care for a physically handicapped child)

The median interval free of disease for women who had a relapse was 30.5 months

Stressful events (severe, non severe) and difficulties (severe, non severe)

Relative risk for relapse: after severe events, 5.67 (1.57 to 37.20), p = 0.004; after severe difficulties, 4.75 (1.58 to 19.20), p = 0.004. Events of any severity or non-severe and difficulties of any severity or non-severe did not affect recurrence

Barraclough et al. 1992 [13]

Three home interviews at 4, 24, and 42 months after operation yielded data about the period from 1 year before surgery until 3.5 years afterwards. The Bedford college life events and difficulties schedule was used to assess life events. Interviews were taped and discussed by the investigators

Relapse of breast cancer was confirmed in 47 (23%) of the 204 breast cancer cases; 26 of these had died by the end of the follow-up period (4 to 42 months after operation); 1 patient died from a reason unrelated to cancer

Life events, social difficulties, depressive symptomatology

For severe life events or social difficulties during the year before surgery, the hazard ratio was 0.43 (95% CI 0.20 to 0.93); during the follow-up period, the hazard ratio was 0.88 (0.48 to 1.64). For prolonged major depression before surgery and during follow up, the hazard ratios were 1.26 (0.49 to 3.26) and 0.85 (0.41 to 1.79). respectively. For absence of a full confidant before surgery, figures were 0.93 (0.42 to 2.09), and during the follow-up period figures were 0.86 (0.38 to 1.93)

Morris et al. 1992 [14]

Interview at 3 months post diagnosis, further tests at 6 to 9 months post diagnosis and another interview at 12 months. Follow up at 5 years post diagnosis. Tests used: Wakefield Self Assessment Depression Inventory, Spielberger State Trait Anxiety Inventory, Multidimensional Health Locus of Control Scale, Courtauld Emotional Control Scale

At 5 year follow up: 20 patients had died, 8 were alive with recurrence, 79 were alive without evidence of recurrence

Patient's Responses to Diagnosis (PRD): fighting spirit (PRD 1), denial (PRD 2), anxious preoccupation (PRD 3), stoic acceptance (PRD 4), helplessness/hopelessness (PRD 5)

PRD code was associated with poorer survival p = 0.06. Association of PRD code with recurrence was not clear, p = 0.15. Patients with PRD 1 and 2 had a better prognosis than patients with PRD 3–5, though not statistically significant (p = 0.07 for overall survival and p = 0.19 for recurrence)

Reynolds et al. 1994 [15]

Information about two dimensions of social ties: structural, which reflect marital status, group participation, contacts with friends and relatives (the questions were based on Beckman SNI); and functional, which reflect perceived emotional support (the questions were based on Seeman's study of angiography patients). 87% of interviews took place within 6 months of diagnosis. Follow up information was obtained from Surveillance, Epidemiology, End Results database and National Cancer Institute

Data of survival reported in NCI Black White Cancer Survival Study

Marital situation, church group participation, other group participation, friends/relatives, contacts, social network index, emotional support, instrumental support

Absence of close ties and perceived sources of support were associated with increased breast cancer death rate. White women with few friends had increased death rate (RR = 2.1, CI 1.1 to 4.4). Black and white women with few sources of emotional support had increased breast cancer death rate (RR = 1.8, CI 1.3 to 2.5)

Tross et al. 1996 [16]

Assessment of psychological symptoms prior to chemotherapy using the Symptoms Checklist-90 revised questionnaire. Scores where trichotomized and Global Severity Index was extracted. Sociodemographic (age, ethnicity, education, and so on) and medical data were also collected

Disease free survival for patients with low, medium, high GSI was: 7.48, 7.04 and 4.90 years, respectively. Overall survival for patients with low, medium, high GSI was: 11.62, 10.21 and 9.58 years, respectively

Somatization, obsessive-compulsive symptoms, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism

This study failed to provide evidence that psychological factors contributed to length of disease-free or overall survival of women who received adjuvant chemotherapy for treatment of stage II breast cancer

Buddeberg et al. 1996 [17]

An interview every 12 months (sociodemographic data, attitude toward cancer and quality of life data) and 2 coping questionnaires: Zurich questionnaire of Coping with Illness (ZQCI) and Freiburg Questionnaire of Coping with Illness (FQCI). The ZQCI was administered every 3 months in the 1st year (assessments 1 to 5) and every 6 months during the 2nd and 3rd year (assessments 6 to 9). FQCI every 12 months (assessments 1, 5, 7, 9). ZQCI and FQCI are self-reported measures with five-point answer-scales for each item

5 to 6 years after the primary surgical treatment: 66.4% were recurrence-free and had no signs of cancer disease, 1.9% had a local-regional recurrence, 5.6% were afflicted with distant metastases, 23.4% had died from breast cancer, 1.9% developed a 2nd carcinoma, and 0.9% died from a cardiac disease

Coping strategies based on two questionnaires

There is no steady significant relationship between the different coping strategies and disease outcome

Kreitler et al. 1997 [18]

Filling of four questionnaires (background information, Psychosocial Adjustment to Illness Scale (PAIS), State-Trait Anxiety Inventory, Locus of control) by a mean of 13.34 months after surgery or 9.89 months after end of treatment. Medical parameters were also examined (stage of disease, estrogen/progesterone receptor status). The health state of patients was examined again 3 and 5 years after surgery

After 3 years: 73.96% were in a good state of health and 1.04% had died. After 5 years: 70.83% were in a good state of health and 14.58% had died

Adjustment, locus of control, anxiety

Both medical and psychological variables are significant predictors for good health state on 3 years and survival on 5 years. The most important psychological predictor was adjustment (especially with regard to sexual and social relations)

Tominaga et al. 1998 [19]

Examination of medical records and personal interviews with the patients at first admission

During the study period and up to October 1995, 48 (12%) patients died of breast cancer and 348 (87.4%) patients were alive

Marital status, having children, number of female and male children, participation in the meetings of patients, having a hobby, number of hobbies, religion, habit of smoking, and habit of drinking alcohol

Being a widow was significantly associated with decreased survival (hazard ratio 3.29, 95% CI 1.32 to 8.20, p = 0.011). Having a hobby was associated with longer survival (hazard ratio 0.43, 95% CI 0.23–0.82, p = 0.010). Number of hobbies was associated with longer survival (hazard ratio 0.64, 95% CI 0.41 to 1.00, p = 0.048). The presence of a child did not influence survival, but the number of female children of patients with breast cancer was associated with survival (hazard ratio 0.64, 95% CI 0.42 to 0.98, p = 0.039). Smoking was found to be a significant negative predictor of survival (hazard ratio 2.08, 95% CI 1.02 to 4.26, p = 0.044). Drinking alcohol had a positive impact on survival of breast cancer patients (hazard ratio 0.10, 95% CI 0.01 to 0.72, p = 0.023). Participation in the social circle of breast cancer patients and religion were not significant prognostic factors of survival

Brabander and Gerits 1999 [20]

Chronic stress was measured with the Dutch version of the Hopkins Symptom Check List on the day of admission. Acute stress was measured with the Dutch version of the Depression Adjective Checklist, before and after the communication of the biopsy results. Natural killer activity (NKA) and the number of NK cells (before and after the biopsy results) were determined as indicators of the immunological consequences of acute stress, while measurement of 3-methoxy-4-hydroxy-phenyl-glycol (MHPG; before and after the biopsy results) was used as a neurochemical indicator of acute stress. Patients were also interviewed by means of audiotaped semi-structured interviews on their expectation about the result of the biopsy

After a follow-up period of 3.5 years, 10 (22.7%) patients had relapsed; 9 of the 10 relapsed patients (90%) had developed metastases and 1 patient (10%) had developed a new carcinoma in the other breast

Acute stress and chronic stress

Acute stress and chronic stress were a significant predictor of early relapse at 3.5 years of follow-up

Watson et al. 1999 [21]

Participants completed self-administered questionnaires at 4 to 12 weeks after diagnosis and 1 year later. Mental Adjustment to Cancer (MAC) scale, Courtauld emotional control (CEC) scale, and hospital anxiety and depression (HAD) scale

At 5 years, 395 (68.3%) women were alive and without relapse, 50 (8.65%) were alive with relapse, and 133 (23%) had died (122 (21.1%) of breast cancer)

Patients' reactions to having cancer (fighting spirit, helplessness or hopelessness, anxious preoccupation, fatalism, and avoidance). The extent to which patients suppress negative emotions (anger, anxiety, sadness), and presence of depression or anxiety

Psychological assessment at baseline: women with a high score on the HAD scale category of depression had a significantly increased risk of death from all causes by 5 years (hazard ratio 3.59, 95% CI 1.39 to 9.24). Women with high scores on the helplessness and hopelessness category of the MAC scale had a significantly increased risk of relapse or death at 5 years, compared with women with a low score in this category (hazard ratio 1.55, 95% CI 1.07 to 2.25). Fighting spirit was not associated with disease outcomes. Psychological assessment at 1 year follow-up: the increased risk of death during follow up for the HAD scale category of depression remained significant (adjusted hazard ratio 4.04, 95% CI 1.54 to 10.64) for a score of >11 on HAD scale depression. The effect of MAC helplessness or hopelessness on event-free survival was reduced from baseline (hazard ratio 1.35, 95% CI 0.91 to 200) and was no longer significant

Reynolds et al. 2000 [22]

Patients were followed for survival through 1994 (since 1985 to 1986). They were administered a modified Folkman and Lazarous Ways of Coping Questionnaire. Coping strategies were characterized via factor analysis of the responses. Interviews took place within 3 months of diagnosis. Follow-up information was obtained from Surveillance, Epidemiology, End Results database and National Cancer Institute

218 deaths due to breast cancer (137 black women, 81 white). Median follow up for women who had not died: 107 months

Seven coping strategies; expressing emotions, wishful thinking, problem solving, positive reappraisal, avoidance, escapism

Expression of emotions was associated with better survival (hazard ratio 0.6, 95% CI 0.4 to 0.9). Women who reported both low expression of emotions and low perceived emotional support had shorter survival (hazard ratio 2.5, 95% CI 1.7 to 3.7)

Butow et al. 2000 [23]

Patients answered a series of questionnaires, repeated every 3 months for up to 2 years following study entry. In this paper there is only the analysis of the initial questionnaire of each patient. Self-report adaptation of the Weisman and Wordon General Coping Strategies Scale (COPE), Psychological Adjustment to Cancer scale (PAC), Multidimensional Support Scale (MDSS), Quality of Life measured by GLQ-8 LASA scales, and patients' perceptions of the aim of the treatment at the initial assessment only (four options: complete cure, increased long-term survival, increased short-term survival, or reduction of symptoms)

Survival was measured from date of study entry to date of death or censored at the date of last follow up for surviving patients; 63% died within the study period

Coping strategy, psychological adjustment, social support, quality of life, and perceptions regarding the aim of treatment

The adjustment style of minimization (minimizing the impact of cancer on social, work, and family life) was significantly associated with survival. Patients who minimized the impact of cancer survived longer (median of 29 versus 23.9 months after study entry (hazard ratio 0.932, CI 0.883 to 0.984, p < 0.01). The risk of dying was reduced by 7% for each unit increase in minimisation, and survival time was increased by a median of 5.2% months after study entry for those scoring above the median on minimisation

Weihs et al. 2000 [24]

The collection and interpretation of data regarding psychological assessments begun at least 6 months after recurrence and prior to the known terminal phase (that is after the acute adjustment to breast cancer recurrence and before the effects of terminal illness). Patients completed questionnaires; negative affectivity/mood was measured with the Profile of Mood States and the Taylor Manifest Anxiety Scale (MAS). Restriction of emotions was measured with the Control of Feelings Scale and the Marlowe Crowne (MC) Social Desirability Scale. Chronic anxiety and emotional constraint scores were used to create four emotion regulatory style groups: low anxiety/low emotional constraint, low anxiety/high emotional constraint, high anxiety/low emotional constraint, and high anxiety/high emotional constraint

At end of data collection, 19 of 32 patients had died. Median time from first occurrence to death or last observation was 2.5 years (range 0.9 to 4.4 years). Median survival time after study enrolment to death of last observation was 1.7 years (range 02 to 3.2 years)

Negative affectivity, negative mood states, and restriction of emotions

Bivariable analysis: low chronic anxiety in the context of low emotional constraint predicted low mortality (RR = 0.07, CI 0.009 to 0.52, p = 0.01; low chronic anxiety scores but with high emotional constraint had higher mortality (RR = 3.73, CI 1.21 to 11.51, p = 0.02); high chronic anxiety was associated with increased mortality risk only after the patient's level of emotional constraint was taken into account; emotional constraint, regardless of chronic anxiety level (RR = 6.45, CI 2.17 to 19.16, p = 0.001), and controlled feelings (RR = 3.41, CI 1.0 to 12.0, p = 0.05) predicted increased mortality; negative mood states predicted mortality (RR = 2.64, CI 1.36 to 5.12, p = 0.004), but chronic anxiety when analyzed separately did not do so. Multivariable analysis: Control of feelings remained a significant predictor of survival independent of the dichotomized variable low anxiety/low emotional constraint group versus others (RR = 5.69)

Graham et al. 2002 [25]

Collected data on stressful experiences and depression, interviews (tape recorded and transcribed) carried out every 18 months and covered the period from 12 months before diagnosis to 5 years after diagnosis. Final interview with patients who had a recurrence took place approximately 8 weeks after diagnosis. Collected data on stressful life experiences by using the Bedford College life events and difficulties schedule. At each interview elicited psychiatric symptoms using the structured clinical interview with criteria from the DSM III R

Recurrence of disease was confirmed in 54 (31.6%) women. The overall five year relapse-free survival was 76% (95% confidence interval 68.6 to 81.1) Some patients died soon after recurrence, and four, out of the final interviews, were completed by the woman's closest relative

Discrete life events and longstanding difficulties (for example, divorce, caring for a severely handicapped child)

No evidence that women who have a severely stressful life experience in the year before breast cancer diagnosis, or in the 5 years following are at any increased risk of developing a recurrence of their disease. An episode of depression before diagnosis did not increase the risk of recurrence (hazard ratio 1.22, CI 0.38 to 3.92, p = 0.7). No increased risk of recurrence in women who had had one or more severely stressful experiences in the year before diagnosis compared with women who did not (hazard ratio 1.01, CI 0.58 to 1.74, p = 0.99). In the post-diagnosis period, women who had one or more severely stressful life experiences had a lower risk or recurrence than those who did not (hazard ratio 0.52, CI 0.29 to 0.95, p = 0.03)

Soler-Vila et al. 2003 [26]

42% of the patients were interviewed within 3 months, 90% within 6 months of the date of diagnosis. Participants were interviewed in their homes with the use of a modified version of the questionnaire used in the National Cancer Institute Black/White Cancer Survival Study; this instrument collected information on sociodemographic, health history, medical care, and psychosocial factors

Survival was defined as time from breast cancer diagnosis until death or censoring by last contact date. During the study period there were 135 (41.9%) deaths from any cause and 99 (30.7%) deaths from breast cancer

Coping styles (denial, passive coping, and isolation), perceived emotional support, fatalism, and health locus of control

Lower perceived emotional support at diagnosis was associated with a higher risk of death from any cause (hazard ratio 1.39, 95% CI 1.09 to 1.79, p = 0.009) as well as death from breast cancer (hazard ratio 1.43, 95% CI 1.07 to 1.92)

Soler-Vila et al. 2005 [27]

42% of the patients were interviewed within 3 months, 90% within 6 months and the remaining 10% within 1 year of the date of the diagnosis. Interviews were based on a modified version of the questionnaire used in the National Cancer Institute Black/White Cancer Survival Study, which gathered information on sociodemographics, health history, medical care, and psychological factors

Survival was defined as time from breast cancer diagnosis until death or censoring by last contact date. By the end of the study period (2002), there were 160 deaths from any cause (49.7%), out of which 105 were due to breast cancer (65.6%), 55 due to diseases of the circulatory system (13%) and 13 due to other neoplasms (8%)

Beliefs about cancer detection, treatment, and curability of cancer disease

Perceived cancer incurability was associated with a higher risk of death from any cause (all-cause mortality; hazard ratio 1.67, 95% CI 1.11 to 2.51), though not associated with breast-cancer mortality

Hjerl et al. 2003 [28]

Information about depression was obtained from the Danish Psychiatric case register, which provides information for admissions to all psychiatric departments and hospitals in Denmark. Records of the patients were obtained from Danish Breast Cancer Cooperation Group. Information about death obtained from Mortality Danish National Register of causes of death

During the study period (1977 to 1993) 5,648 patients (27.4%) died from natural causes and 79 patients (0.4%) died from unnatural causes

Depression defined as all affective and anxiety disorders divided and categorized into five ordinal groups (bipolar, unipolar, reactive disorder, dysthymia, anxiety). Preoperative depression was defined as any psychiatric admission with any of the above mentioned ordinal groups at >15 years of age, from April 1969 to December 1993, at least 3 months before breast cancer diagnosis

Preoperative depression was associated with significantly higher relative risk of mortality for late stage breast cancer. The same trend but non-significant was seen in the early stage breast cancer group. The most pronounced effect was noticed in patients with bipolar diagnosis (compared with the other diagnosis)

Goodwin et al. 2004 [29]

Completion of health-related quality of life (HRQOL) and psychosocial questionnaires shortly after breast cancer diagnosis and 1 year later (sent and returned by mail). European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), Profile of Mood States (PMOS) questionnaire, Impact of Events Scale (IES), Mental Adjustment to Cancer Scale (MAC), Courtauld Emotional Control Scale (SECS), Psychosocial Adjustment to Illness Scale Self-Report (PAIS-SR). Women were followed through an ongoing review of medical records

50% of the patients were followed ≥6 years, 3 (0.75%) women were followed up for less than 1 year, 55 (13.85%) experienced distant recurrences, and 34 (8.56%) women died of breast cancer; 2 (0.5%) women experienced non-breast cancer-related deaths

Health-related quality of life, mood state, stress response syndrome, coping strategies, emotional control, psychological adjustment to illness

No consistency of associations across outcomes or questionnaires between health-related quality of life and psychosocial status and breast cancer prognosis. There was little evidence of significant prognostic associations of 1 year psychosocial measurements. Out of 140 investigated prognostic associations, only 4 were statistically significant: role functioning (EORTC QLQ-C30) was significantly associated with overall survival (OS; p = 0.031), suggesting that better functioning was associated with a lower risk of death. Cognitive functioning (EORTC QLQ-C30) was associated with distant disease-free survival (DDFS; p = 0.041), suggesting that women who had better cognitive functioning 1 year after breast cancer diagnosis had a reduced DDFS. On the PAIS, domestic environment was associated with OS (p = 0.049), suggesting that women who experienced a great deal of illness and disease on domestic environment had an increased risk of death. The avoidance subscale on the IES was associated with OS (p = 0.014), suggesting that women who scored higher on this subscale had a significant lower risk of death

Osborne et al. 2004 [30]

Hospital Anxiety and Depression Scale (HADS), Duke-UNC Functional Social Support (DUFS), Mental Adjustment to Cancer (MAC). Approximately two-thirds of the patients were interviewed between 5 and 9 months following diagnosis, the remaining one-third was interviewed 9 to 17 months following diagnosis

Minimum time from interview to follow-up was 6.1 years and maximum 7.9 years. Survival was measured from date of interview to date of death from breast cancer, or was censored at the date of last follow-up or date of death from other causes; 18 (29%) patients had died, 14 (23%) from breast cancer, 3 (4.8%) from other causes, and in 1 case the cause of death could not be verified; 5 years after diagnosis there were 11 deaths (18%)

Anxiety, depression, mental adjustment to cancer and social support

Fighting-spirit minimizing the illness; high score in MAC subscale was associated with longer survival (HR 0.77, p = 0.008). No statistically significant effects of anxiety, depression or social support on survival were found. Leukocyte numbers were found to be weakly associated with helplessness and depression (r = 0.26 and 0.29, respectively), T-suppressor cell number with fatalism (0.29), and the lymphocyte stimulation index with confidant support (-0.30) and depression (0.25). Cortisol and prolactin levels were not found to be significantly associated with immune measures or psychosocial measures. No substantial evidence for a psychoneuroimmunological link between psychosocial factors and biological factors.

Weihs et al. 2005 [31]

The number of dependable support persons and the amount of contact with them were assessed within 18 months after diagnosis in women with stage II or III breast cancer. At the time of enrolment (1991 to 1993) patients were assessed for support and disease severity (with the use of the Nottingham Prognostic Index (NPI)) and then monitored for disease status through December 2000. Participants listed the first names of supportive relatives and friends and gave the frequency of contact with each person. To estimate the disease outcome, participants' medical charts were reviewed annually. Treatment aggressiveness was also assessed

Time to recurrence or death was set at the date of enrolment to the study (1991 to 1993) until December 2000. At the end of the study period there were 16 (17.7%) deaths from breast cancer and 21 (23.3%) recurrences, while 3 (3.33%) participants died from other causes

Social support: the number of supportive relatives and friends and the frequency of contact with each one

Survival analyses using the number of dependable supports and NPI (disease severity) as simultaneous predictors showed decreased mortality in participants with a 1 standard deviation increase in dependable supports (SD = four dependable supports): (RR = 0.41, CI 0.21 to 0.80, p = 0.01), and a trend toward decreased recurrence (RR = 0.68, CI 0.42 to 1.1, p = 0.11)

Osborne et al. 2005 [32]

Data were from the Surveillance, Epidemiology and End Results (SEER) tumour registries, merged with Medicare data for the years 1991 through 1995. From the SEER program, information regarding tumour location, size, axillary node status, American Joint Committee on Cancer Stage (AJCC), estrogen receptor status, demographic characteristics (age, sex, race, and marital status), and types of treatment provided within 4 months after the date of diagnosis was obtained. The data from the Medicare program used in the study were the Medicare Provider Analysis Review File, the Hospital Outpatient Standard Analytic file, and the 100% physician/supplier file. Information available through 1998 allowed for 3 years follow-up

Marital status

Unmarried women were at an increased risk of death from breast cancer (hazards ratio 1.25, 95% CI 1.14 to 1.37)

Lehto et al. 2006 [33]

Interviews of the patients based on the Ways of Coping questionnaire (WOC), the MOS Social Support Survey, the Anger Expression Scale (AX/Scale), Life Experience Survey (LES), the Rotterdam Symptom Checklist (RSCL), and the Depression Scale (DEPS)

Survival was measured from the day of diagnosis to the day of advancement of the disease (event-free survival) or date of death (overall survival) or day of the last follow-up (15 February 2005). At 15 February 31 patients had relapsed (30.7%) and 20 (19.8%) had died

Coping strategies, emotional expression, anger expression, perceived available social support, non-cancer life stresses, and quality of life 3 to 4 months after diagnosis

In univariate analysis: emotional defensiveness (p = 0.007) and behavioural escape-avoidance (p = 0.057) were significantly associated with shorter survival. In multivariate analysis: distancing (minimising) coping was associated with longer survival (p = 0.034). Emotional defensiveness (anti-emotionality; p = 0.021), behavioural escape-avoidance coping (p = 0.008), and high level of perceived support (p = 0.009) were associated with shorter survival. Depressive symptoms had a survival-decreasing effect before the coping patterns were added into the final models (p < 0.050). Depressive symptoms and high-perceived support tended to predict a shorter event-free time survival (time without relapse; p = 0.066 and p = 0.074, respectively).

Kroenke et al. 2006 [34]

Social networks were assessed in 1992, 1996, and 2000 with the Berkman-Syme Social Networks Index (SNI). Social support was assessed in 1992 and 2000 as the presence and availability of confidant. Social-emotional support was assessed in 1992 and 2000 as the presence and availability of a confidant

224 deaths (107 of these related to breast cancer) accrued to the year 2004

Social-emotional support (presence and availability of a confidant and the frequency of communication with him/her) and social networks (marital status, church group membership, membership in other community organizations)

Prediagnostic analyses of social networks and survival: women who were socially isolated before diagnosis had a subsequent 66% increased risk of all-cause mortality (hazards ratio (HR) = 1.66; 95% CI 1.04 to 2.65) and a two-fold increased risk of breast cancer mortality (HR = 2.14, 95% CI 1.11 to 4.12) compared with those who were socially integrated. The presence and extent of contact with a confidant was associated with survival. Women without close relatives (HR = 2.65, 95% CI 1.03 to 6.82), friends (HR = 4.06, 95% CI 1.40 to 11.75), or living children (HR = 5.62, 95% CI 1.20 to 26.46) had increased risk of breast cancer mortality and of all-cause mortality (HR = 1.66, 95% CI 0.93 to 2.97; HR = 2.20, 95% CI 1.01 to 4.81; and HR = 4.03, 95% CI 1.65 to 9.86, respectively) after diagnosis, compared with those who were socially integrated. Participation in religious or community activities, having a confidant and being married were not associated with survival. Postdiagnostic analyses of social networks and survival: lower social networks, following diagnosis, were not significantly associated with survival. Participation in group activities postdiagnosis appeared to predict a slightly lower risk of mortality (HR = 0.70, 95% CI, 0.44 to 1.11). The presence and extent of contact with a confidant was not associated with survival