Cancer survivors' responses to daily stressors: implications for quality of life.

Due to advances in detection and treatment, approximately 2 in 3 adults diagnosed with cancer today can be expected to survive more than 5 years (Ries et al., 2006). This improved survival rate, combined with the aging population, has led to a substantial increase in the number of cancer survivors in the U.S., now numbering more than 10.5 million individuals (Ries et al., 2006). While the medical concerns of cancer survivors are gaining attention (Hewitt, Greenfield, & Stovall, 2005; President’s Cancer Panel, 2005–2006), there is also growing interest in understanding their psychosocial concerns and quality of life. Most research has focused on overall emotional well-being or psychological symptoms among cancer survivors. Results are generally encouraging, indicating that cancer survivors show comparable levels of psychological functioning to age-matched comparison groups (Bradley, Lutgendorf, Rose, Costanzo, & Anderson, 2006; Dorval, Maunsell, Deschenes, Brisson, & Masse, 1998; Ganz, Rowland, Desmond, Meyerowitz, & Wyatt, 1998; Helgeson & Tomich, 2005; Wenzel et al., 2002). However, several large population-based studies have found that cancer survivors report greater distress and more mental health symptoms relative to those with no cancer history (Arndt, Merx, Stegmaier, Ziegler, & Brenner, 2004, 2005; Baker, Haffer, & Denniston, 2003; Hewitt, Rowland, & Yancik, 2003; Rabin et al., 2007), but comparable functioning in positive domains such as psychological and social well-being (Costanzo, Ryff, & Singer, 2009). The measures used in prior studies capture how cancer survivors respond and adjust to the major life challenge of a cancer diagnosis, treatment, and sequelae. However, it is not known how survivors respond to the routine challenges of every day living, such as day-to-day stressors and hassles related to work or caring for others, for example. If cancer survivors are thought to be a psychologically vulnerable group, as suggested by the aforementioned population-based studies, perhaps they are also more sensitive than others to the stress associated with daily hassles. For example, it is not uncommon for cancer survivors to report posttraumatic stress symptoms, including heightened responses to stress (Jim & Jacobsen, 2008). An alternate hypothesis stems from the transactional model of coping, which posits that stress occurs when appraisal of the demands of a situation exceeds resources for meeting demands (Lazarus & Folkman, 1984), which has subsequently been applied in the context of cancer (e.g., Heim, Valach, & Schaffner, 1997; Stanton & Snider, 1993; Costanzo, Lutgendorf, Rothrock & Anderson, 2006). Specifically, after successfully coping with the demands associated with a serious illness and its treatment, cancer survivors may appraise every-day stressors as less severe and bothersome. In the present study, we investigated cancer survivors’ well-being at the level of day-to-day experiences to test these hypotheses. Specifically, we examined appraisals of daily stressors as well as the affective, somatic, and physiological sequelae of these experiences. While prior research has focused on global emotional functioning or distress related to the cancer experience, we argue that responses to daily stressors may also play a salient role in cancer survivors’ quality of life. Daily stress processes have been shown to contribute to both psychological and physical symptoms in other populations (Almeida, Neupert, Banks, & Serido, 2005; Almeida, Wethington, & Kessler, 2002; Neupert, Almeida, & Charles, 2007). Among cancer survivors, depressed mood, fatigue, pain, and other somatic and affective symptoms are commonly-reported quality of life concerns (Arndt et al., 2005; Arndt, Merx, Sturmer, et al., 2004; Baker et al., 2003; Bower et al., 2006; Carlson et al., 2004; Cella, Davis, Breitbart, & Curt, 2001; Hewitt et al., 2003). It may be that daily stressors could exacerbate these already prominent concerns, and if so, responses to day-to-day hassles could be an important intervention target in this population. Daily stress processes have also been linked to neuroendocrine activity, especially the hormones of the HPA axis, including increased cortisol and disruptions in the daily cortisol rhythm (Jacobs et al., 2007; Smyth et al., 1998; Seltzer et al., 2009; van Eck, Berkhof, Nicolson, & Sulon, 1996). These relationships may have particular relevance for cancer patients and survivors given well-documented associations between cortisol, disrupted circadian rhythms, and cancer development, progression, and survival (Filipski, et al., 2002; Fu & Lee, 2003; Fu, Pelicano, Liu, Huang, & Lee, 2002; Mormont et al., 2000; Schernhammer et al., 2003; Sephton & Spiegel, 2003; Sephton, Sapolsky, Kraemer, & Spiegel, 2000). The present study examined affective, somatic, and cortisol responses to daily stressors in a sample of cancer survivors who were participants in the National Survey of Midlife Development in the United States (MIDUS), designed to study health and well-being during midlife. A subset of MIDUS respondents completed the National Study of Daily Experiences (NDSE), a unique eight-day diary study that assessed participants’ responses to daily events. The large, population-based sample afforded the opportunity to compare respondents with a history of cancer to those with no cancer history. The overall goal was to understand the day-to-day stressful experiences of cancer survivors and their relationships to important biobehavioral sequelae. Stressors involving interpersonal tensions were of particular interest due to the well-documented relationships between perceptions of social relationships and both quality of life and health outcomes among cancer patients (Carpenter, Fowler, Maxwell, & Andersen, 2010; Costanzo et al., 2005; Frick, Motzke, Fischer, Busch, & Bumeder, 2005; Hann et al., 2002; Karnell, Christensen, Rosenthal, Magnuson, & Funk, 2007; Kroenke, Kubzansky, Schernhammer, Holmes, & Kawachi, 2006; Lutgendorf et al., 2005) as well as the ability of social stressors to reliably evoke affective and physiological responses (Birditt, Fingerman, & Almeida, 2005; Dickerson & Kemeny, 2004). The specific objectives were as follows: The first objective was to describe both the frequency and perceptions of daily stressors among cancer survivors as compared to individuals with no history of cancer. We were interested in determining whether cancer survivors differed with respect to appraisal of the severity and impact of stressors that occurred during the study period, with a special focus on those events involving interpersonal tensions. The second objective was to explore relationships between the experience of daily stressful experiences and both quality of life concerns (mood disturbance and physical symptoms) and diurnal cortisol patterns. Specifically, we sought to determine whether affective, somatic, and physiological reactivity to stress differed between cancer survivors and individuals with no cancer history. The goal was to understand whether daily stressors had a disproportionate impact for cancer survivors. We also examined whether the length of time since the initial cancer diagnosis affected cancer survivors’ responses to stress.