Influence of psychological response on survival in breast cancer: a population-based cohort study

Lancet. 1999 Oct 16;354(9187):1331-6. doi: 10.1016/s0140-6736(98)11392-2.


Background: The psychological response to breast cancer, such as a fighting spirit or an attitude of helplessness and hopelessness toward the disease, has been suggested as a prognostic factor with an influence on survival. We have investigated the effect of psychological response on disease outcome in a large cohort of women with early-stage breast cancer.

Methods: 578 women with early-stage breast cancer were enrolled in a prospective survival study. Psychological response was measured by the mental adjustment to cancer (MAC) scale, the Courtauld emotional control (CEC) scale, and the hospital anxiety and depression (HAD) scale 4-12 weeks and 12 months after diagnosis. The women were followed up for at least 5 years. Cox's proportional-hazards regression was used to obtain the hazard ratios for the measures of psychological response, with adjustment for known clinical factors associated with survival.

Findings: At 5 years, 395 women were alive and without relapse, 50 were alive with relapse, and 133 had died. There was a significantly increased risk of death from all causes by 5 years in women with a high score on the HAD scale category of depression (hazard ratio 3.59 [95% CI 1.39-9.24]). There was a significantly increased risk of relapse or death at 5 years in women with high scores on the helplessness and hopelessness category of the MAC scale compared with those with a low score in this category (1.55 [1.07-2.25]). There were no significant results found for the category of "fighting spirit".

Interpretation: For 5-year event-free survival a high helplessness/hopelessness score has a moderate but detrimental effect. A high score for depression is linked to a significantly reduced chance of survival; however, this result is based on a small number of patients and should be interpreted with caution.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anxiety*
  • Attitude to Health
  • Breast Neoplasms / mortality*
  • Breast Neoplasms / pathology
  • Breast Neoplasms / psychology*
  • Cohort Studies
  • Depression / etiology*
  • Disease-Free Survival
  • Female
  • Humans
  • Middle Aged
  • Prognosis
  • Proportional Hazards Models
  • Prospective Studies
  • Social Class
  • Surveys and Questionnaires
  • Survival Analysis