Whitney N. Rebholz

Objective: Depressive symptoms have demonstrated prognostic significance among head and neck cancer patients. Depression is associated with circadian disruption, which is prognostic in multiple other cancer types. We hypothesized that depressive symptoms would be associated with circadian disruption in head and neck cancer, that each would be related to poorer 2‐year overall survival, and that relationships would be mediated by tumor response to treatment.Methods: Patients (N = 55) reported on cognitive/affective and somatic depressive symptoms (PHQ‐9) and wore an actigraph for 6 days to continuously record rest and activity cycles prior to chemoradiation. Records review documented treatment response and 2‐year survival. Spearman correlations tested depressive symptoms and circadian disruption relationships. Cox proportional hazard models tested the predictive capability of depressive symptoms and circadian disruption, separately, on survival.Results: Depressive symptoms were significantly associated with circadian disruption, and both were significantly associated with shorter survival (somatic: hazard ratio [HR] = 1.325, 95% confidence interval [CI] = 1.089‐1.611, P = .005; rest/activity rhythm: HR = 0.073, 95% CI = 0.009‐0.563, P = .012; nighttime restfulness: HR = 0.910, 95% CI = 0.848‐0.977, P = .009). Tumor response to treatment appeared to partly mediate the nighttime restfulness‐survival relationship.Conclusions: This study replicates and extends prior work with new evidence linking a subjective measure of depression and an objective measure of circadian disruption—2 known prognostic indicators—to shortened overall survival among head and neck cancer patients. Continued examination should elucidate mechanisms by which depressive symptomatology and circadian disruption translate to head and neck cancer progression and mortality.

BACKGROUND: Head and neck cancers are associated with high rates of depression, which may increase the risk for poorer immediate and long‐term outcomes. Here it was hypothesized that greater depressive symptoms would predict earlier mortality, and behavioral (treatment interruption) and biological (treatment response) mediators were examined.METHODS: Patients (n = 134) reported depressive symptomatology at treatment planning. Clinical data were reviewed at the 2‐year follow‐up.RESULTS: Greater depressive symptoms were associated with significantly shorter survival (hazard ratio, 0.868; 95% confidence interval [CI], 0.819‐0.921; P < .001), higher rates of chemoradiation interruption (odds ratio, 0.865; 95% CI, 0.774‐0.966; P = .010), and poorer treatment response (odds ratio, 0.879; 95% CI, 0.803‐0.963; P = .005). The poorer treatment response partially explained the depression‐survival relation. Other known prognostic indicators did not challenge these results.CONCLUSIONS: Depressive symptoms at the time of treatment planning predict overall 2‐year mortality. Effects are partly influenced by the treatment response. Depression screening and intervention may be beneficial. Future studies should examine parallel biological pathways linking depression to cancer survival, including endocrine disruption and inflammation. Cancer 2018;124:1053‐60. © 2018 American Cancer Society.

We explored associations between problem-focused, emotional processing, and emotional expression coping strategies and markers of stress including perceived stress, depressive symptoms, and diurnal cortisol profiles among women with gynecologic cancer. Problem-focused coping was associated with less perceived stress, fewer depressive symptoms, and more rhythmic diurnal salivary cortisol profiles. Emotional processing was associated with lower perceived stress and fewer depressive symptoms. Emotional expression was associated with fewer depressive symptoms and elevated diurnal mean and evening cortisol levels. Results point to key differences in coping strategies. In this sample, only problem-focused coping was linked with adaptive differences in both psychological and physiological stress measures.

Women with breast cancer experience significant stress related to diagnosis and treatment, which may negatively affect physiology (e.g., circadian, endocrine, and immune) and contribute to cancer progression. Demographic (e.g., ethnic minority) and neighborhood factors can contribute to cancer-related stress. African American women with breast cancer experience more adverse disease pathology and earlier mortality; however, factors that explain these disparities rarely have been explored. It is hypothesized that psychosocial stressors (i.e., ethnicity, neighborhood stress, and cancerrelated stress) will be related to one another. Associations of psychosocial stress with physiological disruption are posited with regard to circadian, endocrine, and immune function. It is also hypothesized that psychosocial stress and physiological disruption will predict earlier cancer recurrence/mortality. Presurgical breast cancer patients (N=57) reported on demographics and cancerrelated stress and provided three-day home-based collection of rest/activity rhythms and salivary cortisol. Neighborhood stress data were obtained via the 2010 Census. Immune parameters were assessed in serum samples. Progression-free survival status was obtained at a median of seven years post-enrollment. Bivariate correlations examined relationships between psychosocial stressors. Hierarchical linear regressions adjusted for age, cancer stage, and income in tests of associations between psychosocial stress and physiological disruption. Cox proportional hazards analyses tested the prognostic value of psychosocial stress and physiological disruption on progression-free survival from initial diagnosis and study entry. African Americans had higher neighborhood stress compared to non-Hispanic White patients. Patients with greater neighborhood stress had greater overall cortisol secretion (ΔR2 = .246, p = .001). Patients reporting greater cancer-related stress had accentuated diurnal cortisol rhythms (ΔR2 = .084, p = .047). Exploratory post hoc analyses revealed this finding was likely driven by avoidance of cancer-related thoughts. Psychosocial stress was not significantly related to circadian or immune disruption, nor was psychosocial stress or physiological disruption predictive of progression-free survival. Improved resources within disadvantaged neighborhoods may help counter the effects of neighborhood stress on cortisol disruption by reducing stress and improving health outcomes. Interestingly, during the acutely stressful presurgical period, avoidance appears to serve as an adaptive coping strategy. Therefore, the presurgical period may be the opportune time to introduce psychosocial interventions to combat challenges throughout one’s cancer journey.

Poor breast cancer–related quality of life is associated with flattened cortisol rhythms and inflammation in breast cancer survivors and women with advanced disease. We explored the associations of cancer-specific distress (Impact of Events Scale), mood (Profile of Mood States), activity/sleep (wake after sleep onset, 24-hour autocorrelation coefficient) and cortisol (diurnal slope) circadian rhythms, and inflammation (interleukin-6) with quality of life (Functional Assessment of Cancer Therapy–Breast) among patients awaiting breast cancer surgery (N = 57). Models were adjusted for differences in age and cancer stage. Distress and mood disturbance were significantly correlated with lower quality of life. Ethnic differences in the relationship between distress and mood disturbance with global quality of life and subscales of quality of life were observed. Actigraphic measures showed that in comparison with non-Hispanic patients, African Americans had significantly poorer activity/sleep (wake after sleep onset, 24-hour autocorrelation coefficient). Circadian disruption and inflammation were not associated with quality of life. Physiological dysregulation and associated comorbidities may take time to develop over the course of disease and treatment.

Background. Several recent reviews have evaluated evidence on the efficacy of Mindfulness-Based Stress Reduction (MBSR) among fibromyalgia sufferers, a