dissertation - august 2003 enhanced benefit finding in women with early stage breast cancer: the...

Dissertation - August 2003

Enhanced Benefit FindingEnhanced Benefit Findingin Women with Early Stagein Women with Early Stage

Breast Cancer: Breast Cancer:

The Mediational Role of The Mediational Role of

Skill Building and Social Skill Building and Social FunctioningFunctioning


OutlineOutline

1. Introduction in brief1. Introduction in brief

2. Method in brief2. Method in brief

3. Preliminary Analyses3. Preliminary Analyses

4. Changes in Skills4. Changes in Skills

5. Changes in Social Relations5. Changes in Social Relations

6. Predictors of Benefit Finding6. Predictors of Benefit Finding

7. Conclusion7. Conclusion


OutlineOutline




4. Changes in Coping Skills4. Changes in Coping Skills





1.1. Benefit Finding & Breast 1.1. Benefit Finding & Breast CancerCancer

• Effect maintained at 3-month and 9-month follow-ups

EnhancedBenefit Finding

EnhancedBenefit Finding

• Effect of CBSM on Benefit Finding

CBSMIntervention

Emotional Processing

• Benefit Finding was related to increased emotional processing

(Antoni et al., 2001)


1.2. 1.2. GoalGoal

3 Questions:3 Questions:

• Does the CBSM intervention contribute to generate Does the CBSM intervention contribute to generate changes in intrapersonal and interpersonal skillschanges in intrapersonal and interpersonal skills between pre- (T1)and post-intervention (T2) between pre- (T1)and post-intervention (T2) assessments?assessments?

•Does the change in skills b/w T1 and T2 predict Does the change in skills b/w T1 and T2 predict adjustment in social relations atadjustment in social relations at 3-month (T3) and 9- 3-month (T3) and 9-month (T4) month (T4) follow-upsfollow-ups??

• Does Does social relations at T3/T4 mediatesocial relations at T3/T4 mediate the impact of the impact of CBSM on Benefit Finding at T4?CBSM on Benefit Finding at T4?


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• n = 136 (intervention = 60; control = 76)n = 136 (intervention = 60; control = 76)

• Women with early stage Breast Cancer Women with early stage Breast Cancer

• Age range = 29 – 79Age range = 29 – 79

• Stage 0 to Stage IIStage 0 to Stage II

• Self-referralSelf-referral

• Recruited within 1-2 months post-surgeryRecruited within 1-2 months post-surgery

2.1. Sample2.1. Sample


2.2. Variables of 2.2. Variables of InterestInterest• Intrapersonal SkillsIntrapersonal Skills Problem-focused CopingProblem-focused Coping Emotion-focused CopingEmotion-focused Coping

• Intrapersonal SkillsIntrapersonal Skills Seeking support from partnerSeeking support from partner Seeking support from friendsSeeking support from friends

• Social RelationsSocial Relations Social Interpersonal AdjustmentSocial Interpersonal Adjustment Social ProvisionsSocial Provisions Quality of life (social item)Quality of life (social item)

• Benefit Finding T1/T4Benefit Finding T1/T4

EACOPE

SSCOPE

SOCREL

ZBF


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3.1. Control Variables3.1. Control Variables

• Failure to randomizationFailure to randomization– Age + Stage of Cancer + ChemotherapyAge + Stage of Cancer + Chemotherapy

• Control variablesControl variables::– AgeAge– Ethnicity (Black vs. non-Black)Ethnicity (Black vs. non-Black)– Breast Reconstruction (had vs. did not Breast Reconstruction (had vs. did not

have)have)– Chemotherapy (had vs. did not have)Chemotherapy (had vs. did not have)– Tamoxifen (had vs. did not have)Tamoxifen (had vs. did not have)


3.2. Methodological 3.2. Methodological ChoicesChoices

• Primary analyses based on an available-Primary analyses based on an available-case approach (pairwise omission)case approach (pairwise omission)

• Secondary analyses using a complete-Secondary analyses using a complete-case approach (listwise omission)case approach (listwise omission)

• Secondary analyses using Support-Secondary analyses using Support-seeking from friends only (SSCOPE)seeking from friends only (SSCOPE)

• Secondary analyses looking at absolute Secondary analyses looking at absolute scores in coping skills at T2scores in coping skills at T2


Presentation of Presentation of ResultsResults

For each hypothesis:For each hypothesis:

a) Hypotheses testeda) Hypotheses tested

b) Resultsb) Results

c) Discussionc) Discussion

d) Future Directionsd) Future Directions


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4.a. Did the intervention 4.a. Did the intervention generategenerate

Coping Skills (T2)? Coping Skills (T2)? (Hyp. 1)(Hyp. 1)• Hypothesis 1Hypothesis 1: Global treatment effect : Global treatment effect

on coping skills post-intervention (T2)on coping skills post-intervention (T2)

• Model testedModel tested

INTER-PERSONALSKILLS T1


INTRA-PERSONALSKILLS T1

INTRA-PERSONALSKILLS T2CBSM

INTERVENTIONCONDITION


4.b. Did the intervention 4.b. Did the intervention generategenerate

Coping Skills (T2)? Coping Skills (T2)? (Results)(Results)

• No effect of the interventionNo effect of the intervention on on – Intrapersonal Skills (EACOPE) at T2 Intrapersonal Skills (EACOPE) at T2 – Interpersonal Skills (SSCOPE) at T2Interpersonal Skills (SSCOPE) at T2

• But effect of the intervention on But effect of the intervention on emotional emotional processingprocessing (EAC) at T2, with a greater effect (EAC) at T2, with a greater effect for those with lower EAC scores at T1for those with lower EAC scores at T1

• Continuous decreaseContinuous decrease in in – other coping skillsother coping skills (COPE) from T1 to T4(COPE) from T1 to T4– Interpersonal Skills (SSCOPE) from T1 to T4Interpersonal Skills (SSCOPE) from T1 to T4


4.c. Did the intervention 4.c. Did the intervention generategenerate Coping Skills (T2)? Coping Skills (T2)? (Discussion)(Discussion)

• Coping skills at T1 predicted coping skills at T2 Coping skills at T1 predicted coping skills at T2 Minimal changes from T1 to T2 Minimal changes from T1 to T2

• Measures of the use of coping skillsMeasures of the use of coping skills Decrease in coping related to decrease in Decrease in coping related to decrease in perceived stress?perceived stress? A shift from problem-focused coping to emotion-A shift from problem-focused coping to emotion-focused coping and reflection on existential issues?focused coping and reflection on existential issues?

• Use of social support (SS) = only 1 distinctionUse of social support (SS) = only 1 distinction Intervention effective on other facets of SS (e.g., Intervention effective on other facets of SS (e.g., sources, types and quality of SS)?sources, types and quality of SS)?


4.d. Did the intervention 4.d. Did the intervention generategenerate

Coping Skills (T2)?Coping Skills (T2)? (Future Dir.)(Future Dir.)

• Use indicators of Use indicators of acquisitionacquisition of new skills of new skills

• Incorporate a measure of Incorporate a measure of change in change in perceived stressperceived stress concurrent to measure of concurrent to measure of use of coping skillsuse of coping skills

• Select time points with Select time points with greater variations in greater variations in stressstress (e.g., diagnosis vs. post-surgery) (e.g., diagnosis vs. post-surgery)

• Measure Measure other facets of SSother facets of SS: those targeted : those targeted in the intervention (e.g. sources, types, quality in the intervention (e.g. sources, types, quality of social support)of social support)


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5.1.a. Did the 5.1.a. Did the Intervention Intervention EnhanceEnhance Social Social Relations? Relations? (Hyp. 2)(Hyp. 2)• Hypothesis 2Hypothesis 2: Long-term treatment : Long-term treatment

effect on social relations at T3 and T4effect on social relations at T3 and T4

SOCIALRELATIONS

T3/T4

SOCIALRELATIONS T1

CBSMINTERVENTION

CONDITION



5.1.b. Did the 5.1.b. Did the Intervention Intervention EnhanceEnhance Social Relations? Social Relations? (Results)(Results)• No effect of the interventionNo effect of the intervention on Social on Social

Relations as a whole at any time pointRelations as a whole at any time point

Mediation of a treatment effect via skill Mediation of a treatment effect via skill building (Hyp. 3) could not be testedbuilding (Hyp. 3) could not be tested

• T1 reports predictedT1 reports predicted T3/T4 reports of T3/T4 reports of social relationssocial relations

• Increase in social interactionsIncrease in social interactions from T1 from T1 to T3, in the absence of a treatment effectto T3, in the absence of a treatment effect


5.1.c. Did the 5.1.c. Did the Intervention EnhanceIntervention Enhance Social Relations? Social Relations? (Discussion)(Discussion)• Improvement in social interactions in the Improvement in social interactions in the

absence of a treatment effectabsence of a treatment effect

one of the benefits arising from the one of the benefits arising from the experience of breast cancer?experience of breast cancer?

the change in social relations from T1 the change in social relations from T1 to T3 that predicted long-term benefit to T3 that predicted long-term benefit findingfinding


5.1.d. Did the 5.1.d. Did the Intervention EnhanceIntervention Enhance Social Relations? Social Relations? (Future Dir.)(Future Dir.)• To revisit the construct of social To revisit the construct of social

relations; relations; how does it differhow does it differ from the from the beneficial outcomes measured in benefit beneficial outcomes measured in benefit finding?finding?

• Distinction between Distinction between quantitative and quantitative and qualitativequalitative measures of social relations measures of social relations– Frequency of social interactionsFrequency of social interactions– Quality of relationships with family and Quality of relationships with family and

friends and quality of social provisionsfriends and quality of social provisions


5.2.a. Did Change in 5.2.a. Did Change in Skills predictSkills predict Social Relations? Social Relations? (Hyp. 3 & 4)(Hyp. 3 & 4)• Hypothesis 3Hypothesis 3: Mediating effect of skill : Mediating effect of skill

building on change in social relationsbuilding on change in social relations

SOCIALRELATIONS T1

SOCIALRELATIONS

T3/T4





CBSMINTERVENTION

CONDITION



5.2.a. Did Change in 5.2.a. Did Change in Skills predictSkills predict Social Relations? Social Relations? (Hyp. 3 & 4)(Hyp. 3 & 4)• Hypothesis 4Hypothesis 4: Moderating effect of skill : Moderating effect of skill

building on social relationsbuilding on social relations

• Model tested: Model tested:

Outcome variable = SOCREL T3/T4Outcome variable = SOCREL T3/T4Predictors:Predictors:1) SOCREL T11) SOCREL T12) 2) (T2 – T1) EACOPE / SSCOPE(T2 – T1) EACOPE / SSCOPE3) SOCREL T1 * Condition3) SOCREL T1 * Condition


5.2.b. Did Change in 5.2.b. Did Change in Skills predictSkills predict Social Relations? Social Relations? (Results -1)(Results -1)• Skill building did not predictSkill building did not predict (change (change

in) social relations at T3 and T4in) social relations at T3 and T4

• MediationMediation of a treatment effect via skill of a treatment effect via skill building building could not be testedcould not be tested

• No moderating effect of skill buildingNo moderating effect of skill building on T1 levels of social relations as a on T1 levels of social relations as a predictor of later social relationspredictor of later social relations


5.2.b. Did Change in 5.2.b. Did Change in Skills predictSkills predict Social Relations? Social Relations? (Results-2)(Results-2)• T2 interpersonal skills predictedT2 interpersonal skills predicted social social

relations at T3, with a greater effect for those relations at T3, with a greater effect for those who reported lower levels of social relations at who reported lower levels of social relations at baselinebaseline

• T2 intrapersonal skills and SS from friends T2 intrapersonal skills and SS from friends only predictedonly predicted social relations at T4, with a social relations at T4, with a positive effect for those reporting lower levels positive effect for those reporting lower levels of social relations at T1 and a negative effect of social relations at T1 and a negative effect for those with higher levels of social relations for those with higher levels of social relations at T1at T1


5.2.c. Did Skill Building 5.2.c. Did Skill Building predictpredict Social Relations? Social Relations? (Discussion)(Discussion)• Using coping skills (target of the intervention) at Using coping skills (target of the intervention) at T2 should result in better social relations later on T2 should result in better social relations later on (beneficial outcome)(beneficial outcome)

T2 skills predicted frequency of social T2 skills predicted frequency of social interactions and perceived quality of supportinteractions and perceived quality of support

• T1 and T2 skills were highly correlated (r = .50)T1 and T2 skills were highly correlated (r = .50) Change in coping skills did not predict later Change in coping skills did not predict later

social relations (low effect size)social relations (low effect size)

• Benefits to those “who need it the most”Benefits to those “who need it the most” What about the other participants?What about the other participants?


5.2.d. Did Skill Building 5.2.d. Did Skill Building predictpredict Social Relations? Social Relations? (Future Dir.)(Future Dir.)• Further explore the Further explore the negative effectsnegative effects of of

the use of intrapersonal skills on those the use of intrapersonal skills on those who reported higher levels of social who reported higher levels of social relations at T1relations at T1


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6.1.a. Did the 6.1.a. Did the Intervention Enhance Intervention Enhance

Benefit Finding ? Benefit Finding ? (Hyp. 5)(Hyp. 5)• Hypothesis 5Hypothesis 5: Long-term global treatment : Long-term global treatment

effect on benefit finding (BF) at T3 and T4effect on benefit finding (BF) at T3 and T4

• Model Tested:Model Tested:

BENEFITFINDING T3/T4

BENEFITFINDING T1

CBSMINTERVENTION

CONDITION


6.1.b. Did the 6.1.b. Did the Intervention Enhance Intervention Enhance

Benefit Finding ? Benefit Finding ? (Results)(Results)• Effect of the intervention on benefit finding Effect of the intervention on benefit finding

at T3, not at T4at T3, not at T4

Long-termLong-term effect of CBSM intervention effect of CBSM intervention

• Greater positive effect for those who Greater positive effect for those who started with lower levels of benefit finding started with lower levels of benefit finding at baselineat baseline

Positive effect on the participants Positive effect on the participants “who needed it the most”“who needed it the most”


6.2.a. Did Skill Building 6.2.a. Did Skill Building predict predict

Benefit Finding ? Benefit Finding ? (Hyp. 6 & 7)(Hyp. 6 & 7)• Hypothesis 6Hypothesis 6: Long-term effect of skill : Long-term effect of skill

building on benefit finding at T3 and T4building on benefit finding at T3 and T4

• Model tested:Model tested:INTRA-

PERSONALSKILLS T2


BENEFITFINDING T1





6.2.a. Did Skill Building 6.2.a. Did Skill Building mediate mediate

Benefit Finding ? Benefit Finding ? (Hyp. 6 & 7)(Hyp. 6 & 7)• Hypothesis 7Hypothesis 7: Mediating effect of skill : Mediating effect of skill

building on benefit finding at T3 and T4building on benefit finding at T3 and T4

• Model tested:Model tested:



BENEFITFINDING T1

CBSMINTERVENTION

CONDITION INTER-PERSONALSKILLS T2




6.2.b. Did Skill Building 6.2.b. Did Skill Building predict predict

Benefit Finding ? Benefit Finding ? (Results-1 )(Results-1 )• No evidence of a long-term effect of changes in No evidence of a long-term effect of changes in coping skills on benefit findingcoping skills on benefit finding

Change scores did not predict BFChange scores did not predict BF

• T2 Interpersonal skills predicted BF at T3 and T4T2 Interpersonal skills predicted BF at T3 and T4

• Positive effect of T2 intrapersonal skills* on BF at Positive effect of T2 intrapersonal skills* on BF at T3 for those who reported lower BF at T1, and T3 for those who reported lower BF at T1, and negative effect for those who reported higher BFnegative effect for those who reported higher BF

Absolute scores predicted BFAbsolute scores predicted BF* Analyses with SS from friends only & listwise* Analyses with SS from friends only & listwise


6.2.b. Did Skill Building 6.2.b. Did Skill Building mediatemediate

Benefit Finding ? Benefit Finding ? ((Results-2Results-2))• No evidence of a mediation of the long-term No evidence of a mediation of the long-term

treatment effect on BF at T3 via changes in treatment effect on BF at T3 via changes in coping skillscoping skills Skill building did not mediate the long-Skill building did not mediate the long-

term treatment effect on benefit findingterm treatment effect on benefit finding

• No evidence of a mediation of the long-termNo evidence of a mediation of the long-term treatment effect on BF at T3 via T2 coping skillstreatment effect on BF at T3 via T2 coping skills

Coping skills at T2 did not mediate the Coping skills at T2 did not mediate the long-term treatment effect on benefit long-term treatment effect on benefit finding eitherfinding either


6.2.c. Did Skill Building 6.2.c. Did Skill Building predict predict

Benefit Finding ? Benefit Finding ? (Discussion)(Discussion)• Patterns of variations in coping skills may explain Patterns of variations in coping skills may explain these initial results:these initial results: small variations from T1 to T2 (n.s.)small variations from T1 to T2 (n.s.) decrease in most skillsdecrease in most skills instead of a build-up instead of a build-up

• T2(or T1) levels of interpersonal skills predicted T2(or T1) levels of interpersonal skills predicted BF at T3, but the variation (T2-T1) did notBF at T3, but the variation (T2-T1) did not Maybe the predictive part of T2 levels was Maybe the predictive part of T2 levels was already present in T1 levelsalready present in T1 levels

• Other components of the interventionOther components of the intervention contributed contributed to the long-term effect of the intervention on BFto the long-term effect of the intervention on BF


6.2.d. Did Skill Building 6.2.d. Did Skill Building mediate mediate

Benefit Finding ? Benefit Finding ? (Future Dir.)(Future Dir.)• Revise the Revise the operationalization of skill building:operationalization of skill building:

– Changes in skills (not in the Changes in skills (not in the useuse of skills) of skills)– Select time points likely to produce larger effect sizesSelect time points likely to produce larger effect sizes– Concurrent measure of perceived stressConcurrent measure of perceived stress

• Revise the Revise the operational design:operational design:– Address the various changes (frequency, quality)Address the various changes (frequency, quality)– Select different stages (diagnosis, treatment)Select different stages (diagnosis, treatment)– Allow to distinguish intra-individual vs. inter-individual Allow to distinguish intra-individual vs. inter-individual

patterns of change across time pointspatterns of change across time points• What are the What are the other ingredientsother ingredients, which , which

contributed to long-term benefit finding?contributed to long-term benefit finding?


6.3.a. Did Social 6.3.a. Did Social Relations Relations mediate mediate

Benefit Finding ? Benefit Finding ? (Hyp. 8)(Hyp. 8)

• Hypothesis 8Hypothesis 8:Mediating effect of changes :Mediating effect of changes in social relations on Benefit finding in social relations on Benefit finding (T3/T4)(T3/T4)

• Model tested:Model tested:

BENEFITFINDING T1

BENEFITFINDING T4

SOCIALRELATIONS

T3/T4

SOCIALRELATIONS T1






6.3.b. Did Social 6.3.b. Did Social Relations Relations mediate mediate

Benefit Finding ? Benefit Finding ? (Results-1)(Results-1)• Changes in social relations from T1 to T3 Changes in social relations from T1 to T3

predicted benefit finding at T3predicted benefit finding at T3

• Changes in social relations Changes in social relations could not could not mediate the effect of skill buildingmediate the effect of skill building on on benefit finding (benefit finding (absence of such an effectabsence of such an effect)*)*

• Changes in social relations from T1 to T3 Changes in social relations from T1 to T3 did not mediate the treatment effectdid not mediate the treatment effect on on benefit finding at T3benefit finding at T3

* * Yet, mediation evidenced with an analysis listwiseYet, mediation evidenced with an analysis listwise


6.3.b. Did Social 6.3.b. Did Social Relations Relations mediate mediate

Benefit Finding ? Benefit Finding ? (Results-2)(Results-2)

InterpersonalSkills T2

BenefitFinding T3

= .20 (p = .011)

= .20 (p = .036)

= .14 (p = .064)

Social Relations T3

= -.18 (p

= .044)

Interpersonal Skills T2X Social Relations T1

A tentative illustration of a mediation of the relationship between interpersonal skills at T2 and benefit finding at T3

via social relations at T3 (analysis listwise)


6.3.c. Did Social 6.3.c. Did Social Relations Relations mediate mediate

Benefit Finding ? Benefit Finding ? (Discussion)(Discussion)• Improvement in Improvement in social interactionssocial interactions

from T1 to T3 contributed to explain from T1 to T3 contributed to explain enhanced benefit finding at T3enhanced benefit finding at T3

• The absence of a mediating effect of The absence of a mediating effect of social relations again suggests that social relations again suggests that other products of the interventionother products of the intervention contributed to the long-term effect of the contributed to the long-term effect of the intervention on benefit findingintervention on benefit finding


6.3.d. Did Social 6.3.d. Did Social Relations Relations mediate mediate

Benefit Finding ? Benefit Finding ? (Future Dir.)(Future Dir.)• Could the results obtained with a Could the results obtained with a

complete-case approach be reproduced complete-case approach be reproduced with a larger and more complete sample?with a larger and more complete sample?

Replicate the study, with a new methodologyReplicate the study, with a new methodology::– Revise the operationalization of variablesRevise the operationalization of variables– Incorporate a measure of perceived stressIncorporate a measure of perceived stress– Multiple imputations to handle missing dataMultiple imputations to handle missing data– Hierarchical modeling statistical procedureHierarchical modeling statistical procedure– Eventually, collect data prior to surgeryEventually, collect data prior to surgery


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4. Results4. Results

5. Discussion5. Discussion

6. Methodological Limitations6. Methodological Limitations



7.1. Conclusion7.1. Conclusion

3 Factors predicted Benefit Finding3 Factors predicted Benefit Finding at at T3:T3:

• Emotional processing and other coping skills Emotional processing and other coping skills at T2 for those who reported lower levels of at T2 for those who reported lower levels of benefit finding at baselinebenefit finding at baseline

• Support-seeking behaviors at T2Support-seeking behaviors at T2

• Changes in social relations from T1 to T3Changes in social relations from T1 to T3

But did not mediate the treatment But did not mediate the treatment effect observed at T3effect observed at T3


7.2. Conclusion (Cont’d)7.2. Conclusion (Cont’d)

• Diversity of beneficial outcomes for a limited Diversity of beneficial outcomes for a limited range of coping toolsrange of coping tools

some facets of BF may not be some facets of BF may not be influenced by the CBSM interventioninfluenced by the CBSM intervention

• What is measured in the BF scale may be What is measured in the BF scale may be largely independent from what is targeted in largely independent from what is targeted in the CBSM modules (e.g., life readjustment, the CBSM modules (e.g., life readjustment, shift in life priorities and relationships, shift in life priorities and relationships, enhanced sense of purpose)enhanced sense of purpose) Existential/Experiential dimension of BFExistential/Experiential dimension of BF


• Early detection of perceived benefitsEarly detection of perceived benefits

Existential contentExistential content in the in the intervention as early as intervention as early as at the treatment at the treatment stagestage

Need forNeed for indicators indicators of those facets of those facets of benefit finding of benefit finding to measureto measure the impact the impact of the intervention and of the intervention and variationsvariations across across time and situationstime and situations

7.3. Conclusion (Cont’d)7.3. Conclusion (Cont’d)

dissertation - august 2003 enhanced benefit finding in women with early stage breast cancer: the...

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