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Stress and Well-Being in Breast Cancer Survivors: the Influence Of STRESS AND WELL-BEING IN BREAST CANCER SURVIVORS: THE INFLUENCE OF PERSONALITY, SOCIO-DEMOGRAPHICS, CANCER-RELATED CHARACTERISTICS, AND PHYSICAL ACTIVITY LEVELS by Valerie Hadd B.Kin., Université de Montréal, 2002 M.A., The University of British Columbia, 2004 A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in The Faculty of Graduate Studies (Human Kinetics) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) March 2010 © Valerie Hadd, 2010 ABSTRACT Cancer is now considered to be one of the most prevalent chronic diseases in Canada, with breast cancer emerging as the most common type of cancer diagnosed in Canadian women (Canadian-Cancer-Society, 2009). As breast cancer patients move to long-term survivorship, they face new challenges that extend beyond end of treatment (Deimling et al, 2003) which can have direct influences on quality of life (Ferrell et al., 1995). Previous research has often failed to use stress frameworks to examine stress relationships faced by breast cancer survivors (BCS) and has seldom investigated the effect of specific cancer-related stressors and their meaning on quality of life. To address these limitations, the current study investigated the influence of stress-related variables on quality of life of BCS post-treatment using Lazarus’ framework. Moreover, the direct and indirect effects of individual characteristics, including physical activity and personality trait, as well as cancer-related characteristics on stress-related variables were investigated. The final sample included 365 women who had been diagnosed with breast cancer, had completed treatment, and were between the age of 29 and 90 years (Mage = 61.58, SD = 11.36). Structural equation modeling techniques were used to test a hypothesized model based on Lazarus’ framework. The measurement and structural models testing the most global hypothesized model showed good model fit (RMSEA < .08, CFI > .90, TLI > .90), whereby direct and indirect effects of stressors, physical activity, and optimism on quality of life were shown. Together, these constructs explained 61% and 70% of the variance in physical and mental health respectively, highlighting the direct effect of stressors on quality of life above and beyond the role of cognitive appraisal. Experiencing more stressors was significantly associated with reporting lower levels of quality of life. Furthermore, personality had a direct effect on ii mental health whereas being physically active was positively associated with physical health. Overall, findings provided partial support for Lazarus’ model and highlighted some of the potential benefits of physical activity for cancer survivors. These results could be used to guide the design of interventions aimed at increasing physical and mental health in breast cancer survivors. iii TABLE OF CONTENTS ABSTRACT ........................................................................................................................ ii TABLE OF CONTENTS ...................................................................................................iv LIST OF TABLES ............................................................................................................. x LIST OF FIGURES ......................................................................................................... xii ACKNOWLEDGEMENTS ..............................................................................................xiv DEDICATION .................................................................................................................. xv CHAPTER 1: INTRODUCTION ...................................................................................... 1 1.1 Breast Cancer ......................................................................................................... 1 1.1.1 Quality of Life ................................................................................................. 2 1.1.1.1. Individual and cancer-related differences ........................................... 4 1.1.1.2. Physical activity .......................................................................................... 6 1.2. Stress ....................................................................................................................... 8 1.3. Cognitive-Motivational-Relational Theory ......................................................... 9 1.3.1. Cognitive Appraisal ..................................................................................... 11 1.3.2. Measurement of Appraisal ........................................................................... 12 1.3.3. Coping .......................................................................................................... 13 1.4. Stress and Adaptation for Breast Cancer Survivors ....................................... 14 1.4.1. Stressors ....................................................................................................... 14 1.4.2. Cognitive Appraisal ..................................................................................... 18 1.4.3. Coping and Distress Relationship ................................................................ 19 1.4.4. Potential Stress/Quality of Life Moderators/Mediators ............................... 20 1.4.4.1. Age ......................................................................................................... 21 1.4.4.2. Body mass index (BMI) ......................................................................... 22 iv 1.4.4.3. Socio-economic status (SES) ................................................................. 22 1.4.4.4. Personality ............................................................................................. 23 1.4.4.5. Cancer-related characteristics ................................................................ 26 1.4.4.6. Physical activity ..................................................................................... 27 1.5. Summary .............................................................................................................. 29 1.6. Purpose ................................................................................................................. 31 1.7. Objectives ............................................................................................................. 32 CHAPTER 2: METHODS ............................................................................................... 36 2.1. Participants .......................................................................................................... 36 2.1.1. Describing the Participants .......................................................................... 36 2.2. Procedures............................................................................................................ 37 2.3. Measures .............................................................................................................. 38 2.3.1. Stressors ....................................................................................................... 38 2.3.2. Cognitive Appraisal ..................................................................................... 39 2.3.3. Quality of Life .............................................................................................. 40 2.3.4. Personality .................................................................................................... 41 2.3.5. Physical Activity Behavior .......................................................................... 41 2.3.6. Recent Life Events ....................................................................................... 42 2.3.7. Physical Activity Prior to Diagnosis ............................................................ 42 2.3.8. Demographic Information ............................................................................ 43 2.4. Data Analysis ....................................................................................................... 43 2.4.1. Data Screening ............................................................................................. 43 2.5. Preliminary Analysis Strategies ......................................................................... 46 v 2.5.1. Descriptive Statistics .................................................................................... 46 2.5.2. Correlations .................................................................................................. 46 2.5.3. One-Way Multivariate Analysis of Variance .............................................. 46 2.5.4. Linear Regression ........................................................................................ 47 2.5.5. Confirmatory Factor Analysis ...................................................................... 47 2.5.6. Structural Equation Modeling ...................................................................... 49 2.5.7. Personality Variables ................................................................................... 50 2.5.8. Mediation ..................................................................................................... 50 2.5.9. Moderation ................................................................................................... 51 CHAPTER 3: RESULTS ................................................................................................. 54 3.1. Stressors ..............................................................................................................
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