Predicting general and cancer-related distress in women with newly diagnosed breast cancer

In this study, medical variables did not predict anxiety, depression, or cancer-specific distress. This is in contrast to previous research [44], but individuals do not always have adequate knowledge of the medical indices of their disease [45, 46], and hence these variables would not then necessarily predict psychological adjustment.

Overall, illness perceptions predicted a third or more of the variance in general and cancer-specific distress in women with screen-detected breast cancer. Specifically, higher levels of identity predicted greater levels of depression. Identity has been consistently shown to predict adjustment in patients with various forms of cancer, including breast cancer [27, 28, 47], and has been reported as an important predictor of anxiety in a recent meta-analysis [14]. These findings suggest that interventions which address symptom appraisal and symptom management may be useful in regulating anxiety and depression at diagnosis.

Illness coherence was the only illness perception to predict cancer-related distress, but it accounted for 32% of the variance. Women with newly diagnosed breast cancer may feel less distressed about their breast cancer if they have a clear sense of the disease and a greater understanding of it. Illness coherence may overlap with perceived knowledge and studies have shown that perceived receipt of more disease-specific information [48] and higher satisfaction with such information [49] are related to better understanding of illness in cancer patients. Further research examining the relationships between information provision, illness coherence and cancer distress is needed. Current findings; however, do suggest that strategies to enhance illness coherence at diagnosis may be useful. For example, provision of early stage health education information with clear explanations, may have a role in alleviating cancer distress.

Greater perceived control has typically predicted less anxiety and depression in breast cancer [27, 28], and control has been noted as one of the strongest of the illness perceptions as predictors of depression [14]. It may be that perceived personal control is less important for women who have screen-detected disease, as their prognosis is good and the majority women do not require invasive treatment. Beliefs in emotional causes for example stress or worry, predicted greater depression, but not cancer-specific distress. This may link to the controllability of risk where a person may be more anxious if they are unable to control or modify their exposure to a risk (e.g., stress, family problems). Stress is often considered a cause of breast cancer [50, 51], and can indeed predict health behaviours after a cancer diagnosis [52] as well as anxiety and depression [19]. Further research examining the role of causal attributions in distress as well as behaviour change will indicate how these may be included usefully in future interventions.

Results also support the relevance of coping to emotional adjustment in women with breast cancer. Higher levels of fighting spirit predicted less depression, whilst higher anxious preoccupation predicted greater cancer-related distress, anxiety, and depression. This is in line with the established literature in breast cancer that contends that active coping styles are adaptive, whilst passive or emotion-focused styles such as anxious preoccupation are maladaptive [6, 19]. Women, therefore, who ruminate anxiously on their illness at diagnosis, are at higher risk of both general and cancer-related distress so screening for this would allow for timely psychological support. The findings overall, suggest that illness perceptions outweigh the impact of illness-specific coping as predictors of both general and cancer-related distress in women with breast cancer. However, through anxious preoccupation coping, illness coherence can indirectly affect cancer-related distress. This fits with conclusions in a recent meta-analysis [14]; strategies such as avoidance and venting of emotions rather than positive coping styles mediate the relationship between illness perceptions and adjustment in illness. Modification of coping may, therefore, change the relationship between illness perceptions and cancer-related distress. Illness perceptions may be difficult to modify [28], whereas coping strategies may be more amenable to change. This is one of the few studies to demonstrate the presence of mediation [14, 21, 31], and suggests that reducing anxious negative rumination may help to influence the link between specific illness perceptions and cancer-related distress. Furthermore, this finding validates the SRM model and adds to the literature on the mediational role of negative coping in people with cancer. The differences across outcomes indicate that illness coherence is influential in cancer-related distress, whilst identity, personal control, and causal beliefs influence general anxiety and depression. This underscores the value of including assessment of both general and specific distress when measuring the impact of illness perceptions.

There are limitations to this study. The study was cross-sectional so causal inferences cannot be made. Despite this, it indicates that illness perceptions and coping are influential in distress at diagnosis. The sample had screen-detected disease, and non-responders were more likely to have more invasive disease, requiring more invasive treatment. The results therefore, are only generalisable to women who are diagnosed through screening. The emergence of standardised national screening programmes will reduce the number of self-detected cancers, however, as well as the stage of disease and percentage of invasive cancers, so results here are important for determining how this group responds to a cancer diagnosis. The study has a modest sample size. Recruitment of cancer patients is challenging, especially at diagnosis, and while the response rate for return of questionnaires was disappointing, they were consecutive women attending breast clinics with a confirmed diagnosis of breast cancer.